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PYELOGRAPHY 

(Pyelo-Ureterography) 


A  STUDY  OF  THE  NORMAL  JND  I'.ITIIOLOGIC  JN.ITOMV  Of   THE 
RENAL  PELIIS  .JND  CRETE R 


BY 

WILLIAM  F.  BRAASCH,  M.D. 

MAYO  CLINIC,  ROCHESTER.  MINNESOTA 


CONTAINING  296 
PYELOGRAMS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1915 


Copyright,  1915,  by  W.  B.  Saunders  Company 


3-T 


PRINTED    IN    AMERICA 


PREFACE 


It  is  now  almost  ten  years  since  Voelcker  and  von  Lich- 
tenberg  first  succeeded  in  demonstrating  by  means  of  pyel- 
ography the  outline  of  the  human  renal  pelvis  and  ureter. 
This  method,  which  was  at  first  disregarded,  has  been  recently 
more  fully  developed  and  appreciated.  In  all  this  time  no 
comprehensive  collection  of  the  various  types  of  pelvic  out- 
line has  been  published.  The  interpretation  of  the  great 
variety  of  pelvic  deformities  outlined  in  the  pyelogram  is 
difficult  and  is  possible  only  through  familiarity  with  the 
various  types.  The  publication  of  a  series  of  plates  em- 
bodying many  of  the  different  outlines  of  the  pelvis  and 
ureter  seen  in  routine  pyelography  would  seem  to  be  of  some 
practical  value.  With  this  end  in  view  I  have  selected  a 
number  of  plates  from  the  several  thousand  made  at  the 
Mayo  Clinic  during  the  past  five  years,  trusting  that  these, 
together  with  their  description  and  comments,  may  increase 
the  value  of  the  method  and  permit  the  more  general  usage 
which  it  deserves. 

I  wish  to  acknowledge  my  indebtedness  to  Drs.  William 
J.  and  Charles  H.  Mayo  for  placing  at  my  disposal  the  clini- 
cal material  for  this  monograph;  to  Dr.  A.  B.  Moore  and 
Mr.  E.  L.  Taylor,  of  the  roentgenographic  department  for 
making  the  original  radiographic  plates ;  to  Dr.  Franz  Wild- 
ner  for  assistance  in  the  compilation  of  data;  to  my  asso- 
ciates, Drs.  G.  J.  Thomas  and  J.  L.  Crenshaw,  for  assistance 
in  the  development  of  the  technic;  and  to  Mrs.  M.  H, 
Mellish  and  staff  for  assistance  in  compiling  the  literature, 
editing,  and  proof-reading. 

William  F.  Braasch. 

Rochester,  Minn. 
March,  1915 

13 


CONTENTS 


CHAPTER  I 

The  History  of  Pyelography 17 

Bibliograph}' 32 

CHAPTER  II 

Technic 36 

CHAPTER  III 

The  Normal  Pelvis 44 

CHAPTER  IV 

Abnormal  Position r 79 

Movable  Kidney .  79 

Torsion  of  the  Kidney 94 

Dystopic  or  Pelvic  Kidney 95 

CHAPTER  V 

Mechanical  Dilatation 98 

The  Pelvis — Hydronephrosis 98 

The  Ureter — Hydro-ureter 135 

CHAPTER  VI 

Inflammatory  Dilatation 145 

The  Pelvis— Pyelitis 145 

The  Ureter — Ureteritis 166 

Renal  Tuberculosis 172 

CHAPTER  VII 

Renal  Stone 183 

Shadow  Identification 183 

Shadow  Localization 192 

Gall-stones 216 

15 


16  CONTENTS 

CHAPTER  VIII 

Ureteral  Stone 227 

CHAPTER  IX 

Renal  Tumor 252 

Renal  Neoplasm 252 

Tumor  of  the  Renal  Pelvis 276 

Extrarenal  Tumor 277 

Polycystic  Kidney 278 

Solitary  Cyst 285 

CHAPTER  X 

Congenital  Anomaly 289 

Duplication  of  the  Renal  Pelvis 289 

Duplication  of  the  Ureter 301 

Fused  Kidney 306 

Congenital  Large  Pelvis 309 


Bibliographic  Index 315 

Index  of  Subjects 317 


PYELOGRAPHY 

CHAPTER  I 
THE  HISTORY  OF  PYELOGRAPHY 

Probably  the  first  attempt  to  render  the  urinary  tract 
opaque  to  the  x-ray  was  made  by  Tuffier  ^  in  1897.  He 
suggested  the  simultaneous  combination  of  an  opaque 
ureteral  catheter  and  radiography.  Schmidt  and  Ko- 
lischer,"  in  1901,  independently  suggested  the  same  method 
and  published  radiograms  which  showed  the  course  of 
the  ureter  and  the  situation  of  the  renal  pelvis  by  means 
of  a  fused  wire  inserted  into  the  ureteral  catheter  with 
simultaneous  radiography.  They  developed  the  possibili- 
ties of  this  method  and  demonstrated  its  value  in  vari- 
ous conditions.  In  1901  Lowenhardt  ^  described  somewhat 
similar  methods,  as  did  also  von  Illyes  ^  the  following  year. 
In  1905  Fen  wick  ^  suggested  for  the  same  purpose  the  use 
of  a  ureteral  bougie  with  its  walls  impregnated  with  metal. 
These  methods  were  the  forerunners  of  the  use  of  Uquid 
solutions  opaque  to  the  :c-ray  for  the  purpose  of  rendering 
the  outline  of  the  ureter  and  renal  pelvis  visible  in  the 
radiogram,  a  method  which  has  been  called  pyelography  or, 
to  be  more  exact,  pyelo-ureterography. 

The  development  of  the  history  of  pyelography  may  be 
considered  from  the  following  standpoints:  (1)  Technic; 
(2)  diagnostic  data;   and  (3)  accidents  arising  from  its  use. 

Technic. — Probably  inspired  by  his  ability  to  outline 
the  alimentary  tract  with  bismuth,  Klose,*'  in  1904,  sug- 
2  17 


18  PYELOGRAPHY 

gested  the  injection  of  an  emulsion  of  bismuth  into  the 
pelvis  and  the  ureter  with  simultaneous  radiography.  This 
method  failed,  however,  because  the  resulting  shadow  was 
uncertain,  and  it  was  found  difficult  to  remove  the  particles 
of  bismuth  w^hich  adhered  following  the  injection.  It 
remained  for  Voelcker  and  von  Lichtenberg,^  in  1906,  first 
to  demonstrate  successfully  the  complete  outline  of  the 
ureter  and  renal  pelvis  in  the  radiogram.  They  were  the 
first  to  suggest  the  use  of  colloidal  silver  (collargol)  for  this 
purpose.  In  attempting  to  outline  the  bladder  in  the  radio- 
gram it  was  discovered  in  one  of  their  plates  that  the  solu- 
tion had  entered  the  ureter  and  renal  pelvis  also,  causing 
them  to  be  outlined  in  the  radiogram.  Encouraged  by  this 
discovery,  they  injected  a  2  per  cent,  solution,  and  later  a  5 
per  cent,  solution,  through  the  ureteral  catheter  into  the 
pelvis  of  the  kidney  and  were  able  to  report  the  results  of  a 
successful  series  of  pyelograms.  The  value  of  this  method 
was  slow  to  be  recognized,  and,  consequently,  received  but 
little  attention  until  three  or  four  years  later.  Within  the 
last  three  or  four  years,  however,  the  method  has  received 
wide-spread  recognition,  and  is  at  present  extensively  em- 
ployed. 

Various  other  forms  of  colloidal  silver  have  been  sug- 
gested by  some  observers.  Ai-gyrol,  in  solutions  of  40  or 
50  per  cent.,  was  advanced  by  Keyes  ^  in  1909;  silver 
oxid  or  cargentos,  by  Uhle  and  Pf abler  ^  in  1910;  nargol 
and  electrargol,  by  others,  ^"arious  solutions  other  than 
colloidal  silver  have  been  advocated.  In  1913  Doderlein 
and  Kronig  ^°  suggested  the  use  of  xeroform  (15  to  20  per 
cent,  in  olive  oil).  Attempts  were  made  to  render  the  out- 
line of  the  pelvis  and  ureter  visible  by  means  of  injecting 
gas  instead  of  liquid  solutions.     Bm'khardt  and  Polano,^^ 


THE    HISTORY    OF    PYELOGRAPHY  10 

in  1907,  first  suggested  injecting  oxygen  into  the  pelvis 
for  this  purpose.  In  1911  von  Lichtenberg  and  Dietlen '- 
reported  a  series  of  pyelograms  made  with  the  use  of  oxy- 
gen, and  recommended  its  substitution  for  colloidal  silver. 
However,  the  use  of  the  gaseous  medium  did  not  receive 
wide-spread  recognition,  since  the  resulting  outline  was 
frequently  uncertain  and  hard  to  differentiate  from  that 
of  gas  in  the  bowel.  The  use  of  an  emulsion  of  silver  iodid 
was  suggested  first  by  Uhle  and  Pfahler.^  Recently  Kelly 
and  Lewis  ^^  (1913)  have  also  recommended  it  and  demon- 
strated a  series  of  pyelograms  where  it  was  used  to  ad- 
vantage. They  claim  that  it  cast  as  good  a  shadow  as 
colloidal  silver,  without  causing  any  of  the  ill  results  which 
have  been  reported  to  follow  the  latter. 

The  various  solutions  had  usually  been  injected  into  the 
renal  pelvis  by  means  of  a  hand  syringe.  Since  the  degree 
of  pressure  by  this  method  was  uncertain,  and  since  it 
was  impossible  always  to  determine  when  the  capacity  of 
the  pelvis  had  been  reached,  effort  was  made  to  discover 
a  safer  method  of  injection.  For  the  purpose  of  overdis- 
tending  the  renal  pelvis  a  gravity  method  apparatus  was 
first  suggested  by  Baker  "  in  1910.  The  same  year  this 
method  was  first  applied  to  pyelography  by  Uhle  ^  and  his 
coworkers.  They  placed  the  solution  in  a  tube,  which  was 
held  at  a  short  distance  above  the  level  of  the  patient,  and 
allowed  the  fluid  to  distend  the  pelvis  and  ureter  by  grav- 
ity. Oehlecker,^^  in  1911,  also  advised  injecting  the  solu- 
tion by  means  of  the  gravity  method,  rather  than  by  the 
syringe.  In  the  same  year  a  similar  method  was  suggested 
by  Stanton  ^^  and  Bruce.  ^^  In  1913  Thomas  ^^  described 
a  simple  apparatus  for  the  bilateral  injection  by  the  grav- 
ity method.     Following  the  recommendation  of  observers 


20  PYELOGRAPHY 

with  wide  experience,  the  gravity  method  is  now  almost 
universally  employed. 

The  importance  of  a  careful  preparation  of  the  injected 
solution  was  emphasized  by  the  writer  in  1913.^^  He 
recommended  that  the  colloidal  silver  crystals  be  pul- 
verized, dissolved  in  lukewarm  water,  and  then  carefully 
filtered;  otherwise  in  the  10  per  cent,  solution  large  par- 
ticles of  silver  might  be  deposited  in  the  pelvis  and  possibly 
cause  irritation.  He  further  recommended  that  there  be 
no  delay  in  making  the  radiogram  after  the  kidneys  had 
been  catheterized,  and  that  the  injection  and  radiogram 
should  be  made  simultaneously.  Kidd  '^^  also,  in  1914, 
urged  that  the  renal  pelvis  should  be  subjected  to  pressure 
by  the  solution  injected  but  a  short  time — preferably  less 
than  a  minute. 

The  position  of  the  patient  while  the  pyelogram  is  being 
made  is  usually  dorsal.  In  1912  Fowler  ^^  recommended 
a  subsequent  pyelogram  made  in  the  erect  position,  in 
order  to  observe  the  degree  of  renal  excursion.  Schramm,^- 
in  1913,  recommended  the  moderate  Trendelenburg  po- 
sition, in  order  more  completely  to  distend  and  outline  the 
ureter. 

The  size  of  the  plate  varies  with  the  purpose  for  which  it 
is  made,  and  with  the  size  of  the  field  required.  In  1911 
Oehlecker  ^"^  recommended  a  40  x  50  cm.  plate,  so  that  the 
entire  urinary  tract  might  be  outlined.  He  emphasized 
the  value  of  comparing  the  outlines  in  both  renal  pelves 
and  ureters.  Objections  to  this  method  may  be  raised  on 
the  grounds  of  possible  injury  to  both  kidnej^s  because  of 
incorrect  technic. 

The  opinions  of  different  authors  vary  as  to  the  degree 
of  pain  that  should  be  caused  on  injection  of  the  solution. 


THE    HISTORY    OF    PYELOGRAPHY  21 

The  majority  of  them  say  that  mild  pain  should  be  the 
signal  for  stopping  the  injection.  In  1913  Childs  and 
Spitzer  -^  stated  that  severe  pain  should  be  the  signal  for 
ceasing  injection.  The  writer, ^^  however,  has  claimed  (in 
1913)  that  pain  is  unnecessary  and  should  be  avoided. 

The  greater  the  concentration  of  the  solution,  the  clearer 
will  be  the  outline  following  its  injection,  but  it  is  a  common 
experience  that  the  more  concentrated  solutions  are  irri- 
tating. A  10  per  cent,  solution  is  now  most  commonly 
employed,  though  it  is  maintained  by  some  that  a  5  per 
cent,  solution  will  usually  suffice  to  outline  with  complete- 
ness and  safety.  In  1908-09  Albarran  and  ErtzbischofT  ^^ 
recommended  a  7  per  cent,  solution,  as  did  also  Nogier  and 
Reynard  -^  in  1911. 

The  possibility  of  outlining  the  dilated  ureters  after 
filling  the  bladder  with  colloidal  silver  was  first  suggested 
by  von  Lichtenberg  ^^  in  1909.  In  1911  Clark  2'  also  de- 
scribed this  method,  advising  the  Trendelenburg  position, 
so  that  the  fluid  would  more  readily  enter  the  ureters.  In 
1913  the  writer  ^^  recommended  the  method  in  selected 
cases,  but  called  attention  to  the  fact  that  its  use  was 
necessarily  limited. 

Diagnostic  Data. — Attention  was  first  called  to  the 
value  of  pyelography  as  an  aid  to  diagnosis  by  Voelcker 
and  von  Lichtenberg  ^  in  1906.  They  emphasized  its  value 
in  the  diagnosis  of  hydronephrosis,  and  also  suggested  that 
it  might  prove  to  be  of  use  in  the  diagnosis  of  renal  tumor 
and  anomaly,  although  they  did  not  then  refer  to  any  actual 
demonstration  of  such  data.  Albarran  and  Ertzbischoff  ^^ 
were  probably  the  first  to  follow  the  suggestions  of  Voelcker 
and  von  Lichtenberg,^  and  in  1908  published  a  summary  of 
their   experiences.     Although    they   suggested   the   various 


22  PYELOGRAPHY 

possibilities  of  the  method,  their  results  were  incomplete 
and  unsatisfactory.  It  remained  for  later  observers  to 
note  the  full  value  of  the  method  and  to  develop  its  pos- 
sibilities in  the  diagnosis  of  numerous  conditions  in  which 
its  use  has  been  demonstrated.  Diagnostic  data  derived 
from  pyelography  may  be  found  in  articles  by  the  writer 
from  1909  to  the  present  time  (1914).^^  In  papers  read  in 
1909  "^  and  1910  ^°  he  called  attention  to  its  value  in  the 
diagnosis  of  the  following  conditions:  (1)  Normal  pelvis; 
(2)  hydronephrosis;  (3)  pyelitis;  (4)  pyonephrosis;  (5) 
renal  tuberculosis;  (6)  renal  tumor;  (7)  renal  and  ureteral 
anomaly;  (8)  monoc3^stic  and  polycystic  kidney;  (9) 
identification  of  renal  shadows;  (10)  localization  of  renal 
shadows;  (11)  identification  of  ureteral  obstruction;  and 
(12)  as  an  aid  to  ascertain  renal  function.  This  summary 
may  be  said  to  include  practically  all  possible  conditions 
in  which  the  method  has  been  found  to  be  of  value. 

The  early  writings  of  Voelcker  and  von  Lichtenberg 
demonstrated  the  possibility  of  diagnosing  the  existence 
of  a  hydronephrosis  by  means  of  pyelography,  von  Lich- 
tenberg again  described  several  types  of  hydronephrotic 
dilatation  in  1909,-^  and  referred  to  the  diagnosis  of  movable 
kidney  and  ureteral  kinks.  In  1909  Keyes  ^  described  in 
detail  changes  taking  place  in  the  calyces  as  the  result 
of  mechanical  obstruction.  He  coined  the  term  ''plug-hat 
pelvis"  to  describe  the  appearance  of  the  hydronephrotic 
pelvis.  In  a  paper  read  in  1909  -^  the  writer  also  described 
various  types  of  hydronephrosis,  with  illustrations,  and  in 
1911  ^^  he  called  attention  to  the  value  of  the  method  in  the 
diagnosis  of  early  hydronephrosis.  In  1911  Key  ^-  reported 
several  cases  of  hydronephrosis  with  excellent  illustrations. 
In  1912  Fowler  ^^  emphasized  its  value  in  the  diagnosis  of 


THE    HISTORY    OF    PYELOGRAPHY  23 

small  dilatation  of  the  pelvis.      In   1913   Cabot"*''    further 
emphasized   this   point,   and   stated   that   it   is   frequently 
the   only   method   whereby   early   hydronephrosis   can   be 
diagnosed.     He  also  claimed  the  relation  of  the  ureter  to 
the  pelvis  to  be  of  diagnostic  importance  in  early  hydro- 
nephrosis.    In  1911  Oehlecker^'^  referred  to  the  value  of 
pyelography  in  the  diagnosis  of  dilatation  in  hydroneph- 
rosis and  pyonephrosis.     He  described  several  pyelograms 
showing  the  dilatation  of  the  renal  pelvis  and  ureter  which 
frequently  accompanies  pregnancy.     In  1911,  and  again  in 
1913,  Walker,^*  in  a  paper  devoted  to  the  diagnosis  of  hydro- 
nephrosis,   described   further   details    of   the   method.     In 
1913  Voelcker  ^^  gave  a  detailed  description  of  the  gradual 
process  of  pelvic  dilatation,  and  differentiated  between  the 
mechanical  and  inflammatory  types  of  dilatation.     Prob- 
ably the  most  recent  paper  on  the  subject  is  one  by  the 
writer  ^^  in  which  the  details  and  possible  variations  of  the 
outhnes  in  the  different  stages  of  hydronephrosis  are  de- 
scribed.    The   value   of   the   method   in   the   diagnosis   of 
hydronephrosis   has   been   recognized   by   numerous   other 
observers,   among  whom  may  be   mentioned   Nogier   and 
Reynard,25  Bruce,"  Necker,^^  Jaches  and  Furniss,^^  Keene,^^ 
and   Legueu,    Papin,    and    Maingot.'*''      In    1912   Fowler  ^^ 
called  attention  to  the  method  of  making  a  pyelogram  with 
the  patient  first  in  the  dorsal  and  then  in  the  erect  position. 
In  this  manner  the  full  degree  of  excursion  of  both  kidneys, 
when  movable,   as  well  as  the   consequent  course  of  the 
ureters,  can  be  more  accurately  ascertained. 

The  writer  was  probably  the  first  to  describe  the  various 
changes  in  the  outhne  of  the  pelvis  and  ureter  as  the  result 
of  inflammation.29' 30  In  a  recent  article  (1914)  he  de- 
scribed further  details  of  the  various  changes  found  in  the 


24  PYELOGRAPHY 

different  stages  of  inflammatory  destruction,^^  In  1911 
Key  ^^  published  several  excellent  plates  showing  dilatation 
as  the  result  of  infection.  In  a  paper  written  in  1912  deal- 
ing with  the  value  of  pyelography  in  the  diagnosis  of  various 
conditions  Paschkis  and  Necker  ^-  state  that  the  dilatation 
seen  with  inflammation  is  due  to  ureteral  obstruction.  In 
1913  Voelcker  ^^  described  in  detail  the  stages  of  inflamma- 
tory change  in  the  pelvic  outline.  In  1913  Keene  ^^  also  de- 
scribed the  form  of  dilatation  seen  in  both  the  renal  pelvis 
and  the  ureter  as  a  result  of  inflammation.  In  1911  Clark  ^^ 
described  the  method  of  outlining  the  ureter  dilated  as  the 
result  of  inflammation  by  means  of  injecting  colloidal 
silver  solution  into  the  bladder  with  the  patient  in  the 
Trendelenburg  position  and  simultaneous  radiography. 

In  1910  the  writer  ^^  called  attention  to  the  value  of 
pyelography  in  the  diagnosis  of  renal  tuberculosis  in  cer- 
tain doubtful  cases.  In  1911  Oehlecker  ^'^  stated  that  the 
method  is  occasionally  of  value  in  the  diagnosis  of  renal 
tuberculosis.  Von  Lichtenberg  and  Dietlen  ^^  substanti- 
ated these  reports  in  1911,  and  described  the  various  pos- 
sible deformities  seen  even  in  advanced  tuberculosis.  In 
the  same  year  Nogier  and  Reynard  ^^  described  a  case  of 
renal  tuberculosis  diagnosed  by  means  of  pyelography. 
In  1911  Key  ^^  also  described  the  possible  value  of  pye- 
lography in  certain  cases  of  renal  tuberculosis. 

Although  the  diagnosis  of  renal  tumor  by  means  of  the 
pyelogram  was  suggested  by  Voelcker  and  von  Lichten- 
berg/ as  well  as  by  Albarran  and  Ertzbischoff,-^  they  did 
not  illustrate  nor  describe  the  many  possible  deformities. 
In  1909,-^  and  again  in  1912/^  the  writer  detailed  the  vari- 
ous deformities  which  accompany  tumor,  and  illustrated 
their  more  important  phases.     In  1909  von  Lichtenberg  ^'^ 


THE    HISTORY    OF    PYELOGRAPHY  25 

also  called  attention  to  the  possibility  of  peh'ic  deformity 
as  the  result  of  renal  tumor.  In  1911  Nojj;ier  and  Rey- 
nard -'-'  stated  that  occasionally  renal  tumor  could  be  diag- 
nosed in  no  other  way.  In  1911  Oehlecker  i''  also  called 
attention  to  the  possibility  of  diagnosing  renal  tumor  by 
means  of  the  pyelogram.  These  findings  were  corrob- 
orated subsequently  by  Jaches  and  Furniss,'^'*  Keene,^'^  and 
others.  The  writer  -^  has  called  attention  to  the  value  of 
the  method  in  differentiating  tumor  in  the  extrarenal  organs 
from  renal  neoplasm.  In  1914  Kidd  -"  referred  also  to  the 
aid  given  in  the  differential  diagnosis  of  abdominal  tumor. 

Although  Voelcker  and  von  Lichtenberg  "  were  the  first 
to  suggest  the  use  of  pyelography  in  the  diagnosis  of  con- 
genital anomaly  in  the  urinary  tract,  the  first  detailed  data 
of  the  possibilities  of  the  method  were  furnished  by  the 
writer  in  1910,^°  and  again  in  1912.'^  In  1909  von  Lich- 
tenberg -^  cited  a  case  of  dystopic  kidney  diagnosed  by 
means  of  pyelography.  In  1911  Oehlecker  ^^  emphasized 
the  value  of  the  pyelogram  in  the  diagnosis  of  congenital 
anomaly,  and  cited  a  case  with  duplication  of  the  ureter 
and  pelvis.  In  the  same  year  Nemenow^^  made  a  similar 
observation,  and  cited  a  case  of  pelvic  kidney  which  was 
diagnosed  by  means  of  pyelography.  In  1911  Seelig  ^"^ 
described  a  case  with  bilateral  duplication  of  the  pelves 
diagnosed  by  means  of  pyelography.  In  1914  Joseph  ^^ 
described  the  value  of  the  method  in  the  diagnosis  of  a 
series  of  congenital  anomalies.  In  1914  Kidd  ^°  asserts 
that  congenital  anomaly  is  frequently  overlooked,  and  that 
its  existence  can  frequently  be  ascertained  by  means  of 
pyelography,  or  pyeloradiography,  as  he  terms  the  method. 

That  pyelography  could  be  of  considerable  value  in  the 
diagnosis  of  polycystic  kidney  was  suggested  in   1910  by 


26  PYELOGRAPHY 

the  writer,  ^°  who  demonstrated  with  illustrations  some  of 
the  varieties  of  deformity  accompanying  this  condition. 
His  later  publication  suggested  that  it  might  also  be  of 
value  in  the  diagnosis  of  solitary  cysts. 

The  value  of  pyelography  in  the  identification  as  well  as 
the  localization  of  renal  shadows  was  first  noted  by  the 
writer  in  1910,^0  and  later  fully  described  ^^  (1913).  In  1911 
Oehlecker  ^^  also  described  various  changes  in  the  pelvic 
outline  as  the  result  of  stone,  and  called  attention  to  their 
value  in  the  identification  of  stone.  In  the  same  year 
Holland  ^^  described  the  value  of  the  method  in  the  identi- 
fication of  renal  and  ureteral  shadows,  calling  attention 
to  its  use  in  the  differential  diagnosis  of  gall-stone  shadow. 
In  1911  von  Lichtenberg  and  Dietlen  ^^  wrote  of  the  de- 
sirability of  localizing  stone  shadows  by  means  of  pyelog- 
raphy, and  advised  the  use  of  oxygen  instead  of  colloidal 
silver  for  this  purpose.  In  1911  Nogier  and  Reynard,^^ 
and  in  1913  Keene,^^  recommended  pyelography  in  the 
diagnosis  of  renal  stone. 

The  value  of  the  method  in  the  identification  of  ureteral 
obstruction,  including  that  due  to  lithiasis,  was  described 
by  the  writer  in  1909  ^^  and  1910.^°  He  gave  in  detail  the 
changes  in  the  outline  of  the  ureter  caused  by  a  stone  in  the 
lower  ureter,  and,  furthermore,  called  attention  to  the  value 
of  the  method  in  the  diagnosis  of  certain  forms  of  stricture 
of  the  ureter.  In  1910  Uhle  ^  and  his  collaborators  also 
described  the  value  of  pyelo-ureterography  in  the  diag- 
nosis of  ureteral  obstruction  and  lithiasis.  In  1911,  Oehl- 
ecker^^ described  the  value  of  pyelography  in  the  identi- 
fication of  certain  shadows  in  the  area  of  the  lower  ureter. 
In  the  same  year  Dohan  ^^  referred  to  the  same  method. 
In  1913  Keene  ^^  stated  that  it  had  proved  to  be  of  greater 


THE    HISTORY    OF    PYELOGRAPHY  27 

value  in  the  diagnosis  of  stone  in  the  lower  ureter  than  the 
shadowgraph  catheter,  and  then  described  the  resulting 
ureteral  dilatation.  In  1912  Furniss  ''^  described  in  detail 
the  diagnosis  of  certain  forms  of  stricture  of  the  ureter 
which  could  be  diagnosed  in  no  other  way. 

Accidents. — The  most  recent  phase  of  the  literature 
concerning  the  subject  of  pyelography  deals  with  the 
dangers  attending  its  employment.  A  number  of  reports 
were  made  of  lesions  found  in  the  kidney  after  its  removal, 
showing  destruction  of  the  renal  tissue,  evidently  by  the 
injected  colloidal  silver.  Thus,  in  1911,  Zachrisson  ^- 
reported  considerable  reaction  in  five  days  following  the 
injection  of  colloidal  silver,  and,  on  removing  the  kidney, 
found  that  considerable  destruction  was  present  and  that 
it  was  universally  studded  with  black  silver  deposit.  In 
1911  Oehlecker,^^  on  removing  the  affected  kidney  in  a 
case  of  renal  tumor,  found  the  presence  of  infarcts  in  the 
parenchyma  stained  with  colloidal  silver.  In  1911  Jer- 
vell  ^^  observed  a  wedge-shaped  area  of  gangrene  in  the 
kidney  following  pyelography.  Ekehorn,-^''  in  1911,  found 
renal  edema  on  operating  five  days  after  pyelography. 
Buerger/^  in  1912,  reported  deposits  of  silver  in  surround- 
ing foci  of  suppuration  in  the  cortex  of  the  kidney.  Blum,^*^ 
in  1912,  reported  a  series  of  experiments  on  the  kidney  in 
cadavers,  and  attacked  pyelography  on  the  ground  that  it 
is  a  highly  dangerous  and,  furthermore,  useless  method  in 
diagnosis.  In  1913  the  writer  ^^  reported  three  cases 
operated  on  for  hydronephrosis  in  which  evidence  of  silver 
was  found  in  numerous  infarcts  scattered  in  the  renal 
parenchyma.  He  stated  that  such  necrosis  of  the  tissue 
could  follow  retention  of  colloidal  silver.  If  the  drainage 
from  the  pelvis  is  blocked,  peristalsis  may  force  the  re- 


28  PYELOGRAPHY 

tained  silver  solution  into  the  straight  tubules,  with  re- 
sulting necrosis  of  the  tissues.  Tennant,"  in  1913,  re- 
ported a  case  in  which  the  substance  of  the  kidney  was 
damaged  by  injected  colloidal  silver.  Voelcker,^^  Kelly 
and  Lewis/^  and,  later,  Vest,^^  reported  several  cases  where 
evidence  of  colloidal  silver  was  found  at  operation  in  the 
perirenal  tissue.  In  1914  Mason  ^^  reported  two  cases 
where  a  number  of  infarcts  were  found  in  the  kidney  fol- 
lowing pyelography.  Troell,'^'^  in  1913,  reported  a  case  in 
which  infiltration  of  the  tissue  followed  the  injection  of 
6  or  7  c.c.  of  7  per  cent,  solution  of  colloidal  silver  in  a 
kidney  which  was  otherwise  surgical.  Legueu  and  Papin,*^^ 
in  1913,  described  in  detail  the  various  types  of  lesions  seen 
in  the  kidney  following  infiltration  of  the  parenchyma  with 
colloidal  silver.  They  ascribe  such  lesions  to  overdisten- 
tion  of  the  pelvis  with  the  hand  syringe,  and  have  not  ob- 
served them  since  employing  the  gravity  method.  In 
December,  1913,  Schwarzwald  ^'^  reviewed  to  date  the  acci- 
dents reported  in  the  literature,  of  which  there  were  eight. 
He  found  that  they  were  all  due  to  error  in  technic.  He 
also  reported  a  case  of  a  kidney  removed  for  pyelonephritis 
and  multiple  abscesses  in  which  a  short  time  before  a 
pyelogram  had  been  made.  On  examination  of  the  kidney 
silver  was  found  deposited  in  the  tissues  of  the  diseased 
portion  only.  He  concludes  that  the  silver  particles  do 
not  enter  via  the  blood-stream,  but  probably  through  the 
diseased  or  traumatized  tissues.  He  believes  that  if  the 
technic  is  correct,  no  accidents  should  follow  pyelography. 
Walker,^''  in  July,  1914,  gave  a  detailed  resume  of  the  technic 
involved  in  pyelography.  He  claimed  that  careful  injec- 
tion of  the  pelvis  with  hydrostatic  pressure  will  usually 
obviate  any  injury  to  the  kidney.     He  stated  that  infiltra- 


THE    HISTORY    OF    PYELOGRAPHY  29 

tion  of  the  renal  substance  resulted  from  excessive  pressure, 
prolonged  pressure, .  or  previous  trauma  to  the  pelvis  by 
the  catheter.  He  advised  using  a  small  catheter  to  insure 
return  flow  if  the  pelvis  was  overdistended. 

Fatalities  following  pyelography  have  been  reported  by 
various  observers.     In   1911   Roessle"  reported  a  fatahty 
shortly  after  pyelography  which  he  believed  to  be  due  to 
colloidal  silver  poisoning.     Evidence  of  hemorrhagic  diathe- 
sis   appeared    following     the    injection.     At    postmortem 
the  kidney  showed  silver  substance  embedded  throughout 
the  tissues.     In  1914  Smith  ^^  reported  a  death  following 
pyelography  which  he  attributed  to  be  the  direct  cause. 
In  1913  Rosenblatt  and  Morgandies  ^«  reported  a  fatahty 
some  hours  following  pyelography.     The  patient  died  in 
shock  following  an  injection  of  40  c.c.  of  silver  solution. 
Vest  ^s  reported  a  death  fourteen  days  after  pyelography 
which  he  believed  caused  hemorrhagic  diathesis  and  possi- 
bly death.     In  1914  Hofman^'    reported  a  death  four  days 
after  pyelography  which  was  found  to  be  due  to  rupture 
of  a  hydronephrotic  sac.     Such  an  accident  is  only  illus- 
trative of  technical  error  in  having  used  enough  pressure 
to  cause  rupture,  and  is  not  an  argument  against  pyelog- 
raphy.    Within  the  past  few  months  other  fatalities  have 
been  reported  by  different  American  observers.     It  is  of 
interest  to  note  that  in  practically  every  case  the  solution 
was  injected  with  the  pressure  of  a  hand  syringe.     The 
amount  injected  in  most  instances  was  greater  than  the 
pelvic  capacity. 

Within  the  past  year  a  number  of  papers  have  been  pub- 
hshed  deahng  with  experimental  work  on  animals  in  an 
attempt  to  discover  under  what  circumstances  injuries  to 
the  renal  substance  follow  the  use  of  colloidal  silver  in- 
jection. 


30  PYELOGEAPHY 

Tennant,"  in  June,  1913,  reported  a  series  of  experi- 
ments in  which  he  subjected  the  kidneys  of  pigs  to  a  vary- 
ing degree  of  pressure  with  colloidal  silver  solution  and 
noted  the  results.  He  found  that  by  introducing  the  so- 
lution at  a  pressure  of  over  40  mm.  of  mercury,  infiltration 
of  the  kidney  invariably  resulted. 

Strassman,*'^  in  January,  1913,  reported  the  effect  of 
overdistention  of  the  renal  pelvis  in  rabbits  with  colloidal 
silver  under  moderate  pressure.  He  found  that  the  silver 
particles  were  carried  bj^  the  lymph-spaces  as  far  as  the 
renal  capsule.  By  the  end  of  twenty-four  hours  the  greater 
part  of  the  silver  had  left  the  renal  tissue.  He  concluded 
that,  with  careful  technic,  taking  care  not  forcibly  to  dis- 
tend the  pelvis,  no  injury  should  follow  pyelography. 

Wossidlo,^^  in  December,  1913,  concluded,  from  a  large 
series  of  experiments  on  rabbits,  that  when  the  physiologic 
capacity  of  the  normal  pelvis  was  exceeded  by  a  large 
amount  of  colloidal  silver  solution  injected  under  pressure, 
the  colloidal  silver  entered  the  interstitial  tissue  between 
the  tubules.  With  hydronephrosis,  however,  if  the  pelvic 
capacity  is  overfilled,  the  silver  solution  entered  the  renal 
tissue  via  the  dilated  tubules.  When  a  hydronephrosis 
exists,  no  more  should  be  injected  than  the  amount  first 
drained  away.  He  claimed,  however,  that  no  damage 
would  result  if  the  capacity  of  the  pelvis  was  not  exceeded. 
He  believes  that  if  the  pelvis  is  traumatized,  as  evidenced 
by  hematuria,  colloidal  silver  should  be  injected  with  great 
precaution,  since  it  can  then  more  easily  enter  the  renal 
tissue. 

Kidd,"°  in  January,  1914,  reported  a  series  of  experi- 
ments on  sheep's  kidneys,  when  he  distended  the  pelvis 
with  silver   solution  at  various  pressures.     He  concluded 


THE    HISTORY    OF    PYELOGRAPHY  31 

that  the  element  of  time  under  which  the  pressure  was  made 
was  of  equal  importance  with  the  degree.  He  claimed  that 
the  solution  should  be  injected  at  a  maximum  pressure  of  60 
mm.  of  mercury,  and  that  it  should  be  exerted  less  than  a 
minute;  when  exerted  and  with  greater  pressure  longer, 
the  silver  solution  penetrated  the  renal  substance  to  a 
varying  degree.  He  believes  that  the  mode  of  entrance 
was  via  the  straight  tubules. 

Rehn,'"  in  January,  1914,  reported  similar  results  fol- 
lowing even  moderate  overdistention  of  the  renal  pelvis 
in  rabbits,  and  believes  that  great  care  should  be  used  when 
colloidal  silver  is  injected  into  the  human  kidney. 

In  May,  1914,  Eisendrath  '^  reported  the  results  of 
several  experiments  on  dogs,  with  similar  results.  On 
injecting  a  dog's  renal  pelvis  with  20  c.c.  of  10  per  cent, 
silver  solution  under  pressure  of  100  mm.,  the  animal  died 
within  five  minutes.  Necropsy  showed  quantities  of  silver 
deposited  in  the  various  organs  as  the  result  of  widely  dis- 
tributed silver  embolism.  He  believes  that  this  experi- 
ment explains  the  sudden  deaths  reported  in  the  human. 
He  finds,  however,  that,  as  long  as  only  moderate  pressure 
is  employed  and  the  capacity  is  not  exceeded,  no  harm 
results  from  injecting  the  pelvis  with  silver  solution. 

It  is  very  evident,  therefore,  that  unless  a  pyelogram  is 
made  with  strict  technical  precautions,  it  may  cause  con- 
siderable injury.  However,  in  the  hands  of  those  familiar 
with  the  necessary  technic  and  the  selection  of  cases  it  has 
proved  to  be  a  comparatively  harmless  procedure.  Thus 
the  writer  reported  ^^  a  series  of  over  1000  pyelograms  made 
without  serious  results  to  any  patient.  The  method  is  too 
valuable  in  the  diagnosis  of  many  conditions  in  the  urinary 
tract  to  be  discarded.     EfTort  should  be  made,  however, 


32  PYELOGRAPHY 

to  discover  a  substance  which  will  not  injure  the  kidney 
under  any  circumstances,  and  which  may  be  safely  em- 
ployed in  the  hands  of  those  with  limited  experience. 

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3 


34  PYELOGEAPHY 

38.  Jaches,  L.,  and  Furniss,  H.  D.:    "Radiography  of  the  Distended  (Col- 

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41.  Braasch,  Wm.  F.:    "Infections  of  the  Renal  Pelvis  and  Ureter,"  Texas 

State  Jour.,  1913-14,  ix,  305-308. 

42.  Paschkis,  R.,  and  Necker,  F.:   "Ueber  Pyelographie,"  Mitt.  d.  Gesellsch. 

f.  inn.  Med.  u.  Kinderh.  in  Wien,  1912,  xi,  113. 

43.  Braasch,  Wm.  F.:    "Clinical  Data  on  Malignant  Renal  Tumors,"  Jour. 

Amer.  Med.  Assoc,  1913,  Ix,  274-278. 

44.  Braasch,  Wm.  F.:    "The  Clinical  Diagnosis  of  Congenital  Anomaly  in 

the  Kidney  and  Ureter,"  Ann.  Surg.,  1912,  Ivi,  726-737. 

45.  Nemenow,  M.  N.  J.:   " Zur  Kasuistik  der  angeborenen  Missbildungen  des 

Harnapparatus,"  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,   1911-12, 
xviii,  216-220. 

46.  Seelig,  Albert:    "Ein  Fall  von  beiderseitigen  Verdoppelung  der  Nieren- 

becken  und  Ureteren,"  Zeitschr.  f.  Urol.,  1911,  v,  920-923. 

47.  Joseph,  E.:  "Demonstration  praktischwichtigerPyelographien,"  Zeitschr. 

f.  Urol.,  1914,  viii,  344-347. 

48.  Braasch,  Wm.  F.:    "Clinical  Data  on  Renal  Litbiasis,"  Journal-Lancet, 

1913,  xxxiii,  561-564. 

49.  Holland,  C.  Thurstan:    "Recent  Developments  in  Pyelography,"  Arch. 

Roentgen  Ray,  1910-11,  xv,  371. 

50.  Dohan,    N.:     "Zur    Differentialdiagnose   zwischen    Harnleiterstein   und 

verkalkter  Lymphdrlise,"  Fortschr.  a.  d.  Geb.  Rontgenstrahlen,   1911, 
xvii,  165-168. 

51.  Furniss,   H.   D.:     "Some  Types  of  Ureteral  Obstruction  in  Women," 

Jour.  Amer.  Med.  Assoc,  1912,  lix,  2051-2056. 

52.  Zachrisson,   F.:    "Fall  von  Kollargolinjektion  in  die  Tubuli  recti  der 

Niere,"  Nordiskt.  Mediciniskt  Arkiv.,  1911,  3  f.  XI  afd.  1,  No.  27. 

53.  Jervell,    Kr.:     "Partielle   Gangran   d.    Niere  nach    Pyelographie,"    IX. 

Versamml.  des  nordisch.  chirurgischen  Vereins,  Stockholm,  Centralbl. 
f.  Chir.,  1911,  xxxviii,  1345. 

54.  Ekehorn:    Quoted  by  Key,  Hygiea,  1911,  Ixxxii,  129-180. 

55.  Buerger,  L.:    "CoUargol  in  the  Renal  Parenchyma,"  New  York  Acad. 

Med.,  Genito-urinary  Section,  January  17,  1912,  Amer.  Jour.  Urol., 
1912,  viii,  166-168. 

56.  Blum,  v.:    "Ueber  den  Wert  der  Pyelographie  und  anderer  Methoden 

zum  Nachweise  von  Dilatationen  des  Nierenbeckens,"    Wien.  med. 
Wochenschr.,  1912,  Ixii,  1269-1274. 

57.  Tennant,  C.  E.:   "The  Cause  of  Pain  in  Pyelography,  with  Report  of  Ac- 

cident and  Experimental  Findings,"  Ann.  Surg.,  1913,  Ivii,  893. 

58.  Vest,  Cecil  W.:   "Observations  Following  the  Use  of  CoUargol  in  Pyelog- 

raphy," Johns  Hopkins  Hosp.  Bull.,  1914,  xxv,  74-77. 


THE    HISTORY    OF    PYELOGRAPHY  35 

59.  Mason,  J.  M.:    "Dangers  Attending  Injections  of  the  Kidney  Pelvis  for 

Pyelography,"  Jour.  Amer.  Med.  Assoc.,  1914,  Ixii,  839-844. 

60.  Trocll,  A. :  "Full  af  Pyelografi,  dar  KoUargol  intrangt  i  njurens  Urinkanaler 

och  Malpighiska  Kroppar,"  Hygiea,  Stockholm,  1913,  Ixxv,  17&-183. 

61.  Legueu,  F.,  and  Papin,  E.:  "Technique  et  accidents  de  la  pyelographie," 

Arch.  Urologique,  de  la  chnique  de  Necker,  1913,  i,  12-38. 

62.  Schwarzwald,  R.  T.:    "Zur  Frage  der  Gefiihrlichkeit  der  Pyelographie," 

Beitrage  zur  klin.  Chir.,  1913,  lxxx'^'iii,  287-300. 

63.  Walker,  J.  W.  Thomson:   "Pyelography:   a  Critical  Review,"  Brit.  .Jour. 

of  Surg.,  1914,  ii,  128-131. 

64.  Roessle,  R.:    "Todliche  Kollargolvergiftung,"  Miinchen.  med.  Wochen- 

schr.,  1911,  Iviii,  280. 

65.  Smith,  E.  O.:    "Sudden  Death  Following    Pyelography,"  Amer.  Jour. 

Urol.,  1914,  X,  121-123. 

66.  Rosenblatt    and    Morgandies:     "Pyelographie,"    Verhandl.    d.    deutsch. 

Rontgen.  Gesellsch.,  1913,  ix,  81. 

67.  Hofmann,  Eduard  Ritter  von:    "Ueber  die  Gefahren  der  Pyelographie," 

Folia  Urol.,  1914,  viii,  393-404. 

68.  Strassman,  Georg:  "Uber  die  Einwirkung  vonCollargoleinspritzungen  auf 

Niere  und  Nierenbecken,"  Zeitschr.  f.  urol.  Chir.,  1913,  126-138. 

69.  Wossidlo,    E.:     "Experimentalstudie   zur   Kollargolfiillung   des   Nieren- 

beckens,"  Arch.  f.  klin.  Chirurgie,  1913,  ciii,  44—72. 

70.  Rehn,  E.:    "Experimente  zum  Kapitel  der  Pyelographie,"  Zentralbl.  f. 

Chir.,  1914,  xh,  142-145. 

71.  Eisendrath,  Daniel  N.:   "The  Effect  of  Injecting  Collargol  into  the  Renal 

Pelvis,"  Jour.  Amer.  Med.  Assoc,  1914,  Ixii,  1392,  1393. 


CHAPTER  II 
TECHNIC 

Instrumental  manipulation  of  the  urinary  tract  should 
not  be  made  other  than  such  as  is  necessary  to  arrive  at  an 
accurate  diagnosis.  If  the  diagnosis  can  be  made  complete 
without  pyelography,  its  use  is  contraindicated.  It  has 
been  common  experience,  however,  that  lesions  in  the 
urinary  tract  have  been  discovered  by  means  of  pyelog- 
raphy which  could  not  be  diagnosed  with  clinical  and  radi- 
ographic evidence  and  the  usual  cystoscopic  technic.  On 
the  other  hand,  the  existence  of  lesions  in  the  urinary 
tract  has  been  erroneously  inferred  from  evidence  obtained 
through  clinical,  radiographic,  and  the  usual  cystoscopic 
data  which  the  pyelogram  proved  was  not  present.  It 
will  be  found,  in  the  course  of  routine  examination,  that 
the  diagnosis  is  not  infrequently  uncertain  even  after  a 
careful  radiographic  and  cystoscopic  examination.  Pyelog- 
raphy should  be  employed  as  an  aid  in  determining  the 
actual  condition  present  in  doubtful  cases  only. 

Selection  of  Cases. — Pyelography,  and  frequently 
ureteral  catheterization  as  well,  is  contraindicated  with 
hypersensitive  and  frail  individuals,  who  react  violently 
to  any  manipulation  of  the  uiinary  tract.  Not  infre- 
quently the  prostration,  chills,  and  fever  which  follow  an 
ordinary  cystoscopic  examination  in  such  cases  would  be 
attributed   to    the    use    of   pyelography.     Where    there   is 

36 


TECHNIC  37 

evidence  of  renal  insufficiency,  marked  emaciation,  or  acute 
infection,  any  manipulation  of  the  urinary  tract — and 
pyelography  in  particular — is  usually  contraindicated. 
Again,  with  large  hydronephroses,  when  the  diagnosis  is 
evident  from  the  data  obtained  by  means  of  the  ureteral 
catheter,  pyelography  is  unnecessary. 

The  Selection  of  the  Medium  to  be  Injected. — The 
medium  which  will  cast  a  well-defined  shadow,  which  is 
fluid,  and  yet  causes  no  irritation  in  case  it  should  not 
drain,  is  the  best  for  injection.  Unfortunately,  this  ideal 
medium  has  not  yet  been  discovered.  It  has  been  the  ex- 
perience of  most  observers  that  the  original  solution  of 
colloidal  silver,  as  advanced  by  Voelcker  and  von  Lich- 
tenberg,  is  the  most  satisfactory.  The  objection  to  the 
other  forms  of  colloidal  silver  has  been  the  greater  concen- 
tration necessary  in  order  to  cast  a  shadow  of  equal  density. 
Other  solutions  have  proved  to  be  less  satisfactory  than 
colloidal  silver.  Silver  iodid  emulsion,  which  has  been 
recently  advocated,  although  possibly  less  capable  of 
causing  injury,  unfortunately  is  too  viscid  to  be  employed 
with  the  gravity  method.  A  5  per  cent,  emulsion,  care- 
fully prepared,  will  cast  as  good  a  shadow  in  the  radiogram 
as  a  10  per  cent,  solution  of  colloidal  silver. 

Preparation  of  the  Solution. — If  colloidal  silver  is  em- 
ployed, the  best  results  will  be  obtained  from  a  10  per 
cent,  solution.  Although  a  5  per  cent,  solution,  as  origi- 
nally advanced,  will  usually  outline  the  pelvis  and  ureter, 
the  pyelogram  may  appear  very  dim  and  many  details  be 
lacking.  In  the  preparation  of  the  solution  the  following 
precautions  should  be  taken : 

1.  Colloidal  silver  (collargol)  crystals  should  be  carefully 
ground  in  a  mortar  when  put  in  solution  and  then  filtered, 


38  PYELOGRAPHY 

otherwise  the  undissolved  crystals  may  be  deposited  on  the 
walls  of  the  pelvis  and  ureter  and  act  as  an  irritant. 

2.  The  solution  should  be  warmed  but  slightly  before 
the  injection,  since  it  may  coagulate  even  at  a  temperature 
much  below  that  of  boiling. 

3.  The  solution  should  then  be  filtered  carefully  through 
several  layers  of  linen,  to  prevent  any  large  crystals  which 
may  be  undissolved  from  entering  the  injected  solution.  A 
sediment  will  form  in  solutions  which  have  been  allowed  to 
stand  for  some  time,  and  only  the  upper  or  fluid  portion 
should  be  used.  A  solution  which  is  too  thick  to  pass 
through  a  fine-pointed  needle  should  not  be  injected. 

Method  of  Injection. — When  pyelography  was  first 
employed,  the  solution  was  injected  by  means  of  a  hand 
syringe.  However,  it  was  found  to  be  quite  impossible 
thus  to  estimate  accurately  the  capacity  of  the  pelvis. 
Consequently  it  was  frequently  overdistended,  with  re- 
sulting pain  and  injury  to  the  kidney.  It  was  discovered, 
moreover,  that  a  better  and  a  more  even  distention  could 
be  obtained  by  allowing  the  solution  to  enter  the  pelvis 
of  the  kidney  under  the  pressure  of  gravity.  For  this 
purpose  the  simple  method  was  devised  of  elevating  the 
tube  containing  the  injected  medium  a  short  distance 
above  the  patient,  and  allowing  the  fluid  to  enter  the  renal 
pelvis  and  the  ureter  through  the  ureteral  catheter.  This 
has  proved  to  be  the  most  practical  method  of  injection, 
and  has  been  universally  adopted.  The  tube  containing 
the  medium  to  be  injected  is  graduated  into  cubic  centi- 
meters, in  order  to  ascertain  the  amount  of  fluid  used.  It 
may  be  supported  by  an  adjustable  bracket  attached  to  a 
telescoping  stand,  which  permits  the  fluid  to  enter  under 
the  pressure  of  different  elevations.     The  exact  elevation 


TECHNIC  39 

above  the  level  of  the  kidney  to  which  the  fluid  should  be 
raised  varies  with  the  different  observers.  From  one  to 
two  feet  should  suffice,  depending  upon  the  rapidity  with 
which  the  solution  enters  the  pelvis.  After  the  plate  and 
the  tube  are  placed  in  position,  the  fluid  is  allowed  to  enter 
and  the  amount  entering  the  pelvis  should  be  carefully 
noted.  Unless  there  is  some  evidence  of  pelvic  dilatation, 
4  or  5  c.c.  should  be  allowed  to  flow  in,  and  the  tube  lowered 
to  a  few  inches  above  the  level  of  the  abdomen.  The  radio- 
gram should  then  be  made  while  the  fluid  is  still  entering 
the  pelvis  under  slight  gravity  pressure.  In  this  way  any 
leakage  alongside  the  catheter  will  be  compensated  and  the 
pelvis  kept  fairly  well  filled.  As  a  rule,  4  or  5  c.c.  will 
outline  the  average  pelvis;  if,  however,  possible  dilatation 
is  present,  as  high  as  10  c.c.  may  be  allowed  to  enter  under 
gentle  pressure. 

Pain  caused  by  overdistending  the  pelvis  of  the  kidney 
should  always  be  a  signal  to  stop  further  injection.  As  a 
rule,  little  or  no  pain  should  be  caused  by  the  injection, 
and  it  is  not  necessary  to  insure  an  accurate  pelvic  outline. 
Occasionally  pain  will  be  caused  in  spite  of  every  precau- 
tion, and  it  may  follow  the  injection  of  even  1  or  2  c.c.  of 
the  solution.  This  may  often  be  explained  by  the  fact 
that  the  tip  of  the  catheter  has  lodged  in  the  end  of  a  calyx, 
so  that  the  fluid  overdistends  the  calyx.  A  pyelogram 
should  not  be  made  under  anesthesia,  since  the  safeguard 
of  pelvic  overdistention  would  be  lost. 

The  advantages  of  the  gravity  method  of  injection  are 
numerous.  Danger  of  overdistention  is  largely  obviated 
in  that  the  fluid  will  cause  running  as  soon  as  the  pelvis  is 
filled.  The  pressure  from  gravity  is  so  slight  that  but 
little   damage   to   the   kidney  should  result.     Further,   by 


40  PYELOGRAPHY 

keeping  the  pelvis  distended  under  gentle  pressure  a  com- 
paratively complete  outline  is  insured.  This  is  accom- 
plished safely  and  without  making  it  necessary  for  the  oper- 
ator to  be  near  the  a;-rays.  Again,  the  tube  may  be  lowered 
following  the  pyelogram,  and  may  aid  in  draining  the  in- 
jected solution  from  the  pelvis. 

A  moderately  opaque  catheter  should  be  employed, 
since  occasionally  the  position  and  course  of  the  catheter 
are  of  value  in  the  interpretation  of  the  pyelo-ureterogram. 
As  a  rule,  a  small  ureteral  catheter  should  be  used  when 
possible.  A  No.  5  will  usually  suffice  to  drain  the  injected 
solution,  and  at  the  same  time  is  small  enough  to  allow  the 
superfluous  fluid  to  flow  back  into  the  bladder  with  pelvic 
overdistention.  Drainage  of  the  injected  solution  through 
the  catheter  is  not,  as  a  rule,  necessary.  In  case,  however, 
of  possible  retention  in  the  pelvis,  it  would  be  well  to  drain 
the  pelvis  and  also  flush  it  with  sterile  water  or  boric  acid 
solution  through  the  catheter.  The  catheter  should  be 
introduced  into  the  pelvis  in  order  to  obtain  as  complete 
an  outline  of  the  pelvis  as  possible. 

The  patient  is  placed  in  the  usual  dorsal  position  assumed 
for  renal  radiography.  It  may  be  of  some  value  to  elevate 
the  hips  above  the  level  of  the  kidney,  in  order  to  assist 
the  distention  of  the  ureter.  To  outline  the  ureter  by 
means  of  gravity  from  a  bladder  filled  with  opaque  fluid, 
the  patient  must  assume  an  extreme  Trendelenburg  posi- 
tion. If  a  pyelogram  in  the  erect  position  is  desired,  it  is 
best  obtained  on  a  table  so  adjusted  that  motion  on  the 
part  of  the  patient  is  not  necessary. 

Simultaneous  bilateral  pyelography  as  a  routine  pro- 
cedure is  not  advisable.  Although  no  harm  would  result, 
as  a  rule,  the  possibility  of  retention  because  of  unrecog- 


TECHNIC  41 

nized  bilateral  pathologic  conditions  makes  a  unilateral 
pyelogram  preferable.  Occasionally,  however,  the  data 
which  can  be  ascertained  by  comparison  of  the  pelves  are 
necessary  to  accurate  diagnosis,  and  when  the  possibility 
of  retention  is  excluded,  bilateral  pyelography  may  be 
employed. 

Sources  of  Error. — The  possible  technical  errors  which  will 
lessen  the  excellence  of  the  pyelogram  may  be  due  to  either 
the  radiographic  or  the  cystoscopic  technic.  Needless 
to  say  that  much  of  the  success  of  the  pyelogram  depends 
upon  the  character  of  radiographic  technic.  Unless  all 
the  facilities  for  making  a  good  radiogram  are  at  hand,  a 
pyelogram  should  not  be  attempted.  Further,  it  is  prefer- 
able to  have  the  radiographic  apparatus  in  the  room  where 
the  cystoscopic  examination  and  ureteral  catheterization 
are  made.  Delay  following  ureteral  catheterization  and 
change  in  position  on  the  part  of  the  patient  are  to  be 
avoided.  Error  as  the  result  of  cystoscopic  technic  is 
usually  due  either  to  insufficient  distention  or  dilution  of 
the  injected  solution  by  the  retained  fluid.  Occasionally, 
the  catheter  may  become  plugged  or  coiled,  so  that  the 
solution  cannot  pass  through  it. 

Injurious  Results. — The  accidents  which  have  been  re- 
ported as  the  result  of  pyelography  have  usually  occurred 
because  of  error  in  technic  or  retention  of  the  injected  solu- 
tion. The  technical  errors  have  usually  been:  (1)  Forcible 
overdistention  of  the  pelvis;  (2)  long-continued  pressure; 
(3)  trauma  of  the  pelvic  mucosa.  Probably  the  greatest 
injury  to  the  renal  tissue  may  follow  overdistention  of  the 
pelvis  with  the  colloidal  silver  solution.  As  a  result,  the 
metallic  silver  may  either  be  forced  through  the  straight 
tubules  into  the  parenchyma,  where  it  lodges  and  causes 


42  PYELOGKAPHY 

areas  of  focal  necrosis,  or  it  may  enter  the  blood-vessels 
and  be  carried  as  emboli  into  various  parts  of  the  body. 
Such  an  accident  can  be  avoided  by  means  of  the  gravity 
method  of  injection.  Long-continued  pressure,  even  with 
the  gravity  method,  is  to  be  avoided,  since  the  pelvic 
tissues  may  give  way  if  thus  subjected  to  pressure.  Al- 
though it  is  questionable  if  trauma  to  the  pelvic  tissues 
would  facilitate  the  entrance  of  colloidal  silver  into  the 
renal  tissue,  nevertheless  every  precaution  should  be  taken 
to  guard  against  it. 

It  has  been  found  that  colloidal  silver  injected  into  the 
renal  pelvis,  when  unable  to  drain  out,  will  occasionally 
cause  considerable  irritation  and  even  necrosis  in  the  renal 
tissue.  Pyelography  is,  therefore,  usually  contraindicated 
where  it  is  evident  that  the  injected  fluid  cannot  ultimately 
drain.  Since  the  existence  of  such  marked  obstruction  or 
the  retained  fluid  above  it  can  frequently  be  ascertained 
by  means  of  the  ureteral  catheter  alone,  a  pyelogram  will 
often  be  superfluous. 

The  number  of  accidents  in  the  hands  of  observers  with 
wide  experience  has  been  small  and  of  minor  consequence. 
Where  invasion  of  the  cortex  occurs  in  spite  of  every  pre- 
caution, the  kidney  is  otherwise  surgical  and  would  usually 
be  removed.  Pyelography  has  proved  of  too  great  value 
to  allow  it  to  be  discarded  because  of  occasional  reaction. 
It  should,  however,  be  employed  only  with  the  strictest 
precautions,  where  every  technical  facility  is  at  hand,  and 
by  those  who  are  thoroughly  familiar  with  cystoscopic 
technic  and  its  interpretation.  Every  effort,  however, 
should  be  made  to  discover  some  substance  which  will  not 
harm  the  kidney  when  injected  into  the  pelvis  under  any 


TECHNIC  43 

circumstances,  and  which  will  permit  unrestricted  employ- 
ment. 

Gas  Pyelogram. — Theoretically,  air  or  oxygen  would  be 
admirable  substitutes  for  any  opaque  fluid  and  would 
obviate  the  disagreeable  features  of  the  latter.  Simplicity 
in  the  technic  of  making  the  injection,  absence  of  subse- 
quent pain  or  irritation,  and  rapid  drainage  are  all  argu- 
ments in  favor  of  gas.  However,  the  use  of  gas  with  the 
present  technic  has  not  always  proved  to  be  practical. 
The  first  obstacle  encountered  in  spite  of  careful  preparation 
is  the  difficulty  of  eliminating  gas  in  the  bowel.  Confusion 
of  the  shadow  in  the  renal  pelvis  with  the  shadow  caused 
by  gas  in  the  adjacent  bowel  renders  interpretation  un- 
certain. Further,  it  is  difficult  to  keep  the  pelvis  fully 
distended  with  gas  while  the  pyelogram  is  being  made,  so 
that  the  pelvic  outline  will  fail  to  show  minor  changes  and 
details  which  are  frequently  necessary  to  make  a  diagnosis. 
It  is  also  difficult  to  distend  the  ureter  completely  with  gas; 
thus  the  many  data  to  be  gained  through  evidence  of 
pathologic  change  in  the  outline  of  the  ureter  are  also  lost. 
Its  use,  therefore,  will  probably  remain  limited  to  but  a 
few  conditions.  It  might  be  applicable  to  demonstrating 
large  hydronephroses  where  the  exact  condition  cannot  be 
ascertained  by  means  of  the  ureteral  catheter  alone.  Theo- 
retically, at  least,  it  offers  an  excellent  opportunity  for  the 
localization  of  renal  stone.  The  contrasting  shadows  of 
pelvis  and  stone  will  occasionally  outline  the  exact  position 
of  the  latter,  particularly  if  the  stone  is  situated  in  the 
pelvis  or  at  the  end  of  a  calyx.  Unfortunately,  however, 
the  method  cannot  be  relied  upon,  and  after  the  gas  has 
been  injected,  it  is  advisable  to  make  a  subsequent  pyelo- 
gram with  an  opaque  fluid  in  order  to  insure  definite  results. 


CHAPTER  III 

THE  NORMAL  PELVIS 

The  outline  of  the  normal  renal  pelvis  varies  consider- 
ably in  contour  and  size.  In  order  correctly  to  interpret 
abnormality  in  the  pelvic  outline,  it  is  necessary  to  become 
familiar  with  the  wide  range  of  normal  pelvic  contour.  The 
normal  pelvis  is  said  to  be  made  up  of  the  true  pelvis,  the 
major  calyces,  and  the  minor  calyces.  The  true  pelvis  is 
irregularly  pyramidal  in  shape,  tapering  toward  the  uretero- 
pelvic  juncture.  That  portion  of  its  outline  which  is 
nearest  to  the  vertebrae  may  be  regarded  as  the  median 
border,  and  the  opposite  side  as  its  lateral  border.  The 
major  calyces  are  commonly  three  in  number — the  upper, 
the  middle,  and  the  lower.  The  direction  of  the  upper 
calyx  is  perpendicular  and  slightly  lateral;  that  of  the 
middle  calyx,  horizontal;  while  that  of  the  lower  calyx  is 
downward  and  lateral.  The  major  calyces  are  usually 
connected  by  a  comparatively  narrow  isthmus  where  they 
leave  the  true  pelvis.  They  then  become  broader  and 
finally  subdivide  into  a  variable  number  of  minor  calyces. 
The  minor  calyces  are  seen  as  irregular,  finger-like  pro- 
jections extending  a  short  distance  beyond  the  ends  of  the 
major  calyces.  They  may  be  called  the  terminal  irregu- 
larities of  the  pelvic  outline.  A  typical  normal  pelvis  is 
exemplified  in  Fig.  1,  in  which  the  arrangement  of  the  true 
pelvis  and  the  major  and  minor  calyces  are  clearly  illus- 
trated. However,  the  variation  in  the  normal  pelvic 
outline  is  so  great  that  such  a  pelvis  would  constitute  but 

44 


THE    NORMAL   PELVIS 


45 


Fig.  1. — Normal  pelvis. 


Fig.  2. — Normal  pelvis. 


46 


PYELOGRAPHY 


a  small  percentage  of  the  pelves  that  are  observed  in  routine 
pyelography. 

The  True  Pelvis. — The  outline  of  the  true  pelvis  may 


Fig.  3. — Normal  pelvis. 


17921 


/       __  -...j*/ 


1j 


Fig.  4. — Normal  pelvis. 


Fig.  5. — Normal  pelvis. 


THE    NORMAL    PEI>VIS  47 

assume  a  great  variety  of  forms.  The  outline  may  be 
well  rounded,  as  in  Fig.  2,  squared  as  in  Fig.  3,  or  elongated 
as  in  Fig.  4.  Instead  of  being  symmetric  and  tapering, 
as  in  Figs.  5  and  6,  it  is  frequently  broad  and  squared  at 
the  ureteropelvic  juncture  (Fig.  7).  The  true  pelvis  may 
be  formed  so  that  the  major  calyces  become  practically  a 


Fig.  6. — Normal  pelvis. 

part  of  it,  the  pelvis  leading  directly  into  the  minor  calyces. 
In  Fig.  7  no  distinct  major  calyces  are  present.  Numerous 
small  calyces  lead  directly  from  the  true  pelvis.  In  Fig. 
8  an  unusual  nodular  broadening  of  the  true  pelvis  is  visible 
which  is  probably  due  to  coiling  of  the  end  of  the  catheter. 
The  capacity  of  the  true  pelvis  is  usually  greater  than 


48 


PYELOGKAPHY 


Fig.  7. — Normal  pelvis. 


Fig.  8. — Normal  pelvis. 


THE    NORMAL    PELVIS  49 

that  of  the  combined  calyces.  It  may,  however,  be  much 
smaller,  and  occasionally  is  seen  as  a  slight  rudimentary 
space.  The  pelvis  may  divide  at  but  a  short  distance  be- 
yond the  ureteropelvic  juncture  into  major  calyces,  having 
a  capacity  much  larger  than  the  free  pelvis  itself.  Such  a 
type  of  pelvic  division  may  be  regarded  as  a  distinct  at- 
tempt at  reduplication  of  the  pelvis.  In  Fig.  9  a  true  pelvis 
is   absent.     In   its   place   are   two   divisions   of   the   pelvis 


Fig.  9. — Normal  pelvis. 

which  may  be  regarded  as  elongated  major  calyces,  and 
which  unite  at  the  ureteropelvic  juncture.  The  lower  di- 
vision branches  immediately  into  three  well-formed  sec- 
ondary major  calyces,  while  the  upper  division  branches 
into  several  rudimentary  major  calyces.  In  Fig.  10  the 
combined  capacity  of  the  major  calyces  and  branches  is 
greater  than  that  of  the  true  pelvis. 


50 


PYELOGRAPHY 


When  the  normal  pelvis  is  found  to  be  unusually  large, 
the  increase  in  size  is  confined  more  to  the  true  pelvis  than 


^^       \  CO. 


17952 


Fig.  10. — Normal  pelvis. 


Fig.  11. — Normal  pelvis. 


to  the  calyces.     In  Fig.  11  the  true  pelvis  of  both  kidneys 
is  unusually  broad,  while  the  calyces  are  about  the  usual 


THE    NORMAL    PE1.\'IS  51 

size  and  are  normal  in  outline.  In  Fig.  12  the  true  pelves 
are  exceptionally  large  in  both  kidneys,  while  the  calyces 
are  unusually  small,  although  rather  dimly  outlined.  In 
Fig.  13  the  size  and  shape  of  the  true  pelvis  in  the  right 
kidney  are  such  as  to  suggest  early  hydronephrosis,  though 
this  would  be  precluded  b}-  the  normal  outline  of  the  minor 
calyces. 


Fig.  12. — ^Normal  pelvis. 

When  the  entire  pelvic  outline  is  unusually  small,  the 
diminution  in  size  of  the  true  pelvis  is  shared  by  the  calyces. 
In  Figs.  14  and  15  the  true  pelvis  and  the  calyces  of  both 
kidneys  are  unusually  small. 

Although  the  capacity  of  the  true  pelvis  is,  as  a  rule, 
relatively  symmetric  in  the  two  kidneys,  it  is  not  neces- 
sarily so.     In  exceptional  instances  one  pelvis  may  be  con- 


52 


PYELOGRAPHY 


Fig.  13. — Normal  pelvis. 


Fig.  14. — Normal  pelvis. 


THE    NORMAL    PELVIS 


53 


Fig.  L5. — Normal  pelvi 


«^ 


Fig.  16. — Normal  pelvis. 


54 


PYELOGRAPHY 


siderably  larger  than  the  other.  It  must  be  remembered, 
however,  that  unless  both  pelves  are  equally  distended, 
there  may  be  evident  disparity  in  the  size.  Thus  in  Fig. 
16  the  pelvis  of  the  left  kidney  is  incompletely  distended 
and  appears  much  smaller  than  that  on  the  right  side. 

The  contour  of  the  pelvis  depends  to  some  extent  on  the 
degree  of  distention  by  the  injected  medium.  Unless  the 
pelvis  is  fully  distended,  its  exact  outline  cannot  be  ascer- 


Fig.  17. — Normal  pelvis. 


tained.  Incomplete  distention  may  give  an  erroneous 
impression  of  the  outline  and  may  be  the  source  of  error 
in  interpretation.  In  Fig.  17  both  pelves  are  incompletely 
distended.  The  pelvis  of  the  right  kidney  is  but  partially 
filled,  and  the  calyces  appear  as  irregular,  narrow  streaks 
which  are  suggestive  of  tumor  deformity. 

The  axis  of  the  pelvis  is  usually  perpendicular  and  lateral 


THE    NORMAL   PELVIS  55 

to  a  varying  degree.  When  the  pelvis  is  so  situated  that 
the  calyces  all  extend  caudad  or  median,  the  kidney  is 
abnormally  rotated.  In  Fig.  18  a  rather  unusual  arrange- 
ment of  the  calyces  is  visible,  in  that  a  considerable  dis- 
tance separates  the  upper  calyx  from  the  other  calyces, 
and  also  in  that  the  direction  of  the  pelvic  axis  and  of  the 
other  calyces  is  transverse  and  caudad.  In  Fig.  19  the 
calyces  all  extend  caudad,  showing  the  rotated  position  of 
the  kidney. 


Fig.  18. — Normal  pelvis. 

Major  Calyx. — The  outline  of  the  major  calyx  may  be 
divided  into  three  parts:  (1)  The  base,  or  the  portion  where 
it  leaves  the  true  pelvis;  (2)  the  isthmus,  or  the  cylindric 
portion  which  leads  to  a  variable  distance  from  the  true 
pelvis;  and  (3)  the  apex  or  terminal  portion  of  the  calyx, 
from  which  the  several  minor  calyces  extend.  The  varia- 
tions from  this  common  type  are,  however,  considerable, 
and  it  may  be  difficult  to  identify  the  various  divisions. 

Unusual  length  of  the  isthmus  of  one  or  more  calyces  is 


56 


PYELOGRAPHY 


Fig.  19. — Movable  kidney, 


Fig.  20. — Normal  pelvis. 


THE    NORMAL    PELVIS  57 

not  infrequently  seen.  It  is  more  apt  to  occur  with  the 
upper  calyx,  and  may  be  regarded  as  the  result  of  partial 
reduplication  of  the  pelvis.  In  Fig.  20  the  upper  calyx  is 
connected  with  the  true  pelvis  by  a  long,  narrow  isthmus 
which  extends  upward  an  unusual  distance.  In  Fig.  21 
a  similar  extension  of  the  isthmus  exists  in  the  upper  ma- 
jor calyx  of  the  left  kidney.     In  Fig.  22  the  upper  major 


Fig.  21. — Normal  pelvis. 

calyx  is  markedly  elongated,  and  the  irregularity  of  the 
pelvis  is  such  that  it  might  easily  be  confused  with  de- 
formity caused  by  tumor  retraction.  Fig.  23  illustrates, 
in  the  left  pelvis,  an  extension  of  the  upper  major  calyx  and 
an  unusual  branching  of  the  lower  major,  the  middle  calyx 
being  rudimentary  and  but  a  branch  of  the  lower  major. 
In  the  right  renal  pelvis  both  the  lower  and  upper  calyces 


58 


PYELOGRAPHY 


Fig.  22. — Normal  pelvis. 


Fig.  23. — Normal  pelvis. 


THE    NORMAL    PELVIS  59 

are  retracted.  The  apex  of  the  major  calyx  is  usually 
broader  than  the  lower  portion.  It  may  be  of  considerable 
size,  and  assume  the  characteristics  of  a  secondary  pelvis. 

The  size  and  arrangement  of  the  calyces  of  the  two  pelves 
are  commonly  more  or  less  symmetric.  The  outline  of 
the   individual   calyces   may,  however,   vary   considerably. 


Fig.  24. — Normal  pelvis. 

Marked  asymmetry  in  outline  is  occasionally  present  with- 
out apparent  cause.  In  Fig.  23  the  pecuhar  elongation 
of  the  upper  calyces  is  present  in  both  pelves.  In  Fig.  21 
the  outline  of  the  left  renal  pelvis  is  quite  different  from  the 
right  in  that  the  isthmus  of  its  upper  calyx  is  elongated  to 
an  unusual  extent. 

Ordinarily,  there   are   three  major   calyces;    there  may, 


60  PYELOGRAPHY 

however,  be  an  increase  or  decrease  from  the  usual  number. 
While  frequently  but  two  major  calyces  are  visible,  one 
major  calyx  rarely,  if  ever,  occurs  without  the  presence  of 
some  pathologic  condition  in  the  kidney.  In  Fig.  24  four 
distinct  and  separate  major  calyces  are  visible  in  the  pelves 
of  both  kidneys.  Although  the  distention  of  the  right  pelvis 
is  incomplete,  it  suffices  to  show  the  outline  of  the  calyces. 


Fig.  25. — Normal  pelvis. 

An  increase  in  the  number  of  calyces  is  frequently  seen  to 
be  due  to  the  branching  of  the  major  calyx  into  two  or 
more  secondary  calyces.  Such  branching  occurs  more 
frequently  with  the  lower  major  calyx.  In  Fig.  25  but  two 
major  calyces  are  visible.  The  lower  calyx  divides  into 
three  distinct  branches,  which  may  be  regarded  as  secondary 
major  calyces  or  as  large  minor  calyces.  In  Fig.  18  four 
major  calyces  are  visible  in  both  pelves,  but  the  increase 


THE    NORMAL    PELVIS  61 

in  number  is  seen  to  be  the  result  of  division  of  the  lowest 
major  calyx  into  two  branches.  Actual  increase  of  the 
major  calyces  may  be  simulated  by  divisions  of  the  major 
calyces  at  the  various  planes  in  the  parenchyma.  In  Fig. 
26  a  bilateral  symmetric  arrangement  of  the  major  calyces 
is  visible.  They  are  evidently  four  in  number,  but  on  closer 
inspection  the  lower  two  calyces  aie  seen  to  be  divisions  of 


Fig.  26. — Normal  pelvis. 

the  lower  major  calyx.  An  unusual  number  of  major 
calyces  extend  from  a  diminutive  true  pelvis  in  Fig.  27. 
The  upper  and  lower  major  calyces  subdivide  into  two 
secondary  calyces.  The  pelvis  is  situated  at  an  abnormally 
low  level. 

The  middle  calyx  is  apt  to  be  smaller  than  the  other  two, 
and  may  even  be  very  rudimentary  or  absent  entirely.     It 


62 


PYELOGRAPHY 


Fig.  27. — Normal  pelvis, 


Fig.  28. — Normal  pelvis. 


THE    NORMAL    PELVIS  03 

is  fre(iuently  seen  as  a  secondary  major  calyx  branching 
from  the  lower  major  calyx.  No  evidence  of  the  middle 
calyx  is  visible  in  Fig.  28,  its  place  being  taken  by  an  in- 
crease in  the  size,  an  unusual  degree  of  branching  of  the 
upper  calyx,  and  a  slight  branching  in  the  lower  calyx. 
At  times  the  middle  major  calyx  may  be  obscured  because 
it  is  situated  on  a  different  plane  from  that  of  the  other 


Fig.  29. — Normal  pelvis. 

calyces.  In  Fig.  29  the  borders  of  the  middle  calyx  are 
dimly  seen  at  a  plane  beyond  that  of  the  lower  major  calyx. 
Apparent  Anastomosis. — Apparent  bridging  or  continua- 
tion of  the  lumen  of  different  calyces  may  be  observed  in 
the  pyelogram.  Anastomosis  of  the  calyces  does  not,  how- 
ever, actually  occur,  the  evident  bridging  being  caused  bj^ 
the  fact  that  the  outlines  of  the  calyces  override  at  different 
levels.     In  Figs.  16  and  30  various  major  calyces  are  situ- 


64 


PYELOGRAPHY 


Fig.  30. — Normal  pelvis. 


Fig.  31. — Normal  pelvis. 


THE    NORMAL    PELVIS  65 

ated  at  different  levels,  so  that  they  appear  to  anastomose. 
It  will  be  seen,  however,  that  their  outlines  are  distinct. 

Multiple  branching  of  the  major  calyces  at  irregular 
angles  is  clearly  demonstrated  in  Fig.  10.  A  rather  un- 
usual distribution  of  the  major  cal3'Ces,  which  is  to  be  ex- 
plained partially  by  incomplete  distention,  is  seen  in  Fig. 
31.  A  rather  unusual  and  tortuous  contour  to  the  upper 
calyx  is  seen  in  Fig.  32. 


•  Fig.  32. — Xonnal  pelvis. 

Minor  Calyx. — The  outline  of  the  normal  minor  calyces 
is  usually  characterized  by  an  irregularly  pyramidal  shape, 
extending  from  the  apex  of  the  major  calyx  to  a  variable 
distance  into  the  parenchyma.  Upon  closer  inspection 
these  terminal  irregularities  are  seen  to  be  caused  by  in- 
dentations of  the  minor  papillae  into  the  ends  of  the  calyces. 
The  radiogram  shows  but  one  border  of  these  indentations, 

5 


66 


PYELOGRAPHY 


Fig.  33. — Normal  pelvis. 


Fig.  34. — Normal  pelvis. 


THE    NO  KM  A  L    PEI.VIS 


67 


and  so  gives  the  minor  calyx  a  pyramidal  appearance. 
The  typical  arrangement  and  appearance  of  the  terminal 
irregularity  caused  by  the  minor  calyces  is  well  illustrated 
in  Fig.  33.  Whenever  such  uniform  irregularity  is  present 
in  all  the  calyces,  the  pelvis  may  definitely  be  called  nor- 


Fig.  35.— Normal  pelvis. 

mal,  and  the  absence  of  a  chronic  pathologic  process  in 
the  kidney,  particularly  inflammatory,  may  usually  be  in- 
ferred. 

Several  minor  calyces,  more  or  less  rounded  and  indefi- 
nitely outlined,  may  occasionally  appear  in  the  normal 
pelvis.     Even  though  a  few  of  the  minor  calyces  are  not 


68  PYELOGRAPHY 

well  defined,  as  long  as  the  outlines  of  the  other  calyces  are 
normal,  one  may  usually  infer  that  the  entire  pelvis  is 
normal.  In  Fig.  34  the  minor  calyces  are  not  well  defined 
in  the  upper  major  calyces,  which  appear  rounded.  The 
minor  calyces  in  the  lower  major,  however,  appear  normal, 
and  the  absence  of  other  evidences  of  inflammatory  change 
would  exclude  any  pathologic  lesion.     In  Fig.  35  the  ab- 


Fig.  36. — Normal  pelvis. 

sence  of  the  terminal  irregularities  in  the  upper  calyx  and 
the  general  broadening  of  the  ends  of  the  calyces  are  sug- 
gestive of  inflammatory  changes  there;  however,  the 
presence  of  a  normal  contour  in  the  remaining  calyces  ex- 
cludes the  probability  of  infection. 

As  a  rule,  the  normal  minor  calyces  are  narrow  and  short, 
but  not  infrequently  they  are  seen  to  be  of  considerable  size. 
In  Figs.  25  and  36  the  minor  calyces  are  of  such  size  that 


THE    NORMAL    PELVIS  69 

they  might  be  regarded  as  secondary  major  calyces.  Unless 
the  pelvis  is  well  distended,  the  minor  calyces  may  be  more 
or  less  obscured  and  give  the  impression  of  slight  inflamma- 
tory changes.  Should  the  patient  breathe  or  move  while 
the  pyelogram  is  being  made,  the  outline  of  the  minor 
calyces  may  become  blurred,  and  suggest  the  presence  of  a 
pathologic  process.     In  Fig.  37  the  minor  calyces  in  the 


Fig.  37. — Normal  pelvis. 

right  pelvis  are  but  faintly  visible  because  of  insufficient 
distention. 

Position  of  the  Normal  Renal  Pelvis. — The  position  of 
the  normal  renal  pelvis  as  seen  in  the  pyelogram  taken  in 
the  dorsal  position  varies  considerably.  It  is  usually 
found  at  a  level  of  the  last  rib  or  a  short  distance  below  it. 
With  a  high-lying  kidney  the  upper  calyx  may  often  extend 
as  high  as  the  tenth  intercostal  space,  and,  in  exceptional 


70  PYELOGRAPHY 

instances,  even  as  high  as  the  tenth  rib.  Although  it  would 
be  difficult  to  place  any  arbitrary  limit  to  the  lowest  normal 
level  at  which  the  pelvis  may  be  situated,  nevertheless, 
when  it  is  found  below  the  level  of  the  third  lumbar  vertebra, 
its  position  may  be  regarded  as  abnormal.  When  the 
pyelogram  is  made  subsequently  with  the  patient  in  the 
erect  position,  both  pelves  usually  drop  to  a  varying  degree. 
When  the  kidneys  are  freely  movable,  this  excursion  is 
often  quite  marked. 

The  pelvis  of  the  right  kidney  is  found  to  lie  at  a  lower 
level  than  that  of  the  left  kidney  in  the  majority  of  cases. 
The  difference  in  levels  may  be  slight,  but  more  frequently 
the  right  pelvis  lies  at  least  three  or  four  centimeters  below 
the  left.  Whenever  the  left  pelvis  lies  lower  than  the  right, 
there  is  frequently  some  pathologic  reason  for  it.  In  Fig. 
26  both  pelves  are  situated  unusually  high  and  at  the  same 
level.  The  calyces  are  seen  to  extend  into  the  tenth  inter- 
costal space.  In  Fig.  38  the  upper  calyx  extends  well 
into  the  eleventh  intercostal  space.  In  Fig.  13  the  right 
pelvis  lies  opposite  the  second  and  third  lumbar  vertebrae, 
and  the  left  pelvis  opposite  the  first  and  second. 

The  normal  lateral  limits  of  the  renal  pelvis  are  not  as 
variable  as  the  horizontal.  The  situation  of  the  pelvis 
is  usually  fairly  uniform  in  its  proximity  to  the  vertebrae. 
Its  median  border  is  commonly  in  close  proximity  to  or 
overlapping  the  shadow  of  the  transverse  processes.  Should 
the  pelvis  lie  in  front  of  the  vertebral  column,  or  at  a  con- 
siderable distance  away  from  it,  its  position  must  be  re- 
garded as  abnormal. 

Relation  of  Pelvis  and  Ureter. — The  lower  portion  of 
the  true  pelvis  usually  tapers  gradually  into  the  upper 
ureter,    causing    a    pyramidal    outline    in    the    pyelogram. 


THE    NORMAL    PELVIS 


1 


The  first  portion  of  the  ureter,  extending  as  far  as  the  first 
point  of  narrowing,  is  usually  broader  than  the  ureter 
below  it.  This  is  illustrated  in  Fig.  13.  The  ureter  usually 
leaves  the  pelvis  at  a  point  where  the  median  and  lateral 
borders  meet.  It  may,  however,  leave  the  median  border 
of  the  pelvis  at  some  distance  above  the  lowest  portion  of 
the  lateral  border.     Whenever  the  ureter  leaves  the  pelvis 


Fig.  38. — Normal  pelvis. 


in  an  upward  direction,  it  is  evident  either  that  the  kidney 
is  movable  and  has  rotated  laterally  or  that  a  congenital 
anomaly  is  present.  When  the  ureter  leaves  the  pelvis  from 
its  lateral  border,  it  may  be  inferred  that  either  a  horseshoe 
kidney  or  an  anomalous  rotation  exists.  In  Fig.  19  the 
right  ureter  leaves  the  pelvis  in  a  lateral  and  cephalic  di- 
rection, while  the  left  leaves  in  a  lateral  and  caudad  di- 
rection. 


72  PYELOGRAPHY 

The  angle  formed  by  the  ureter  with  the  lower  surface 
of  the  pelvis  is  usually  broad  and  rounded.  When  the 
angle  is  acute,  it  indicates  either  marked  rotation  as  the 
result  of  renal  excursion  or  pelvic  dilatation.  In  Fig.  39 
the  angle  between  the  ureter  and  the  lower  border  of  the 
pelvis  (particularly  on  the  left  side)  is  acute.  This  is  due 
to  the  position  of  the  kidney,  since  the  pelvis  itself  is  normal. 


Fig.  39. — Normal  pelvis. 

When  the  pelvis  is  incompletely  filled  and  an  opaque 
catheter  is  used,  the  ureter  may  appear  to  leave  the  pelvis 
at  unusual  angles.  This  may  be  explained  by  the  fact 
that  the  elasticity  of  the  ureter  permits  the  catheter  to 
move  in  unusual  positions,  while  the  absence  of  the  colloidal 
silver  fails  to  outline  the  ureteropelvic  juncture.  In  Fig. 
40  the  outline  of  both  pelves  is  unusual,  largely  because  of 
incomplete  distention  of  the  true  pelvis.  Of  particular 
interest  is  the  direction  of  the  opaque  catheter  as  it  leaves 


THE    NORMAL    PliLVIS  73 

the  pelvis.  The  absence  of  the  injected  medium  in  both 
ureters  gives  an  erroneous  impression  of  the  position  of  the 
ureteropelvic  juncture. 

The  Normal  Ureter. — Because  of  the  elasticity  of  the 
walls  of  the  ureter,  and  because  of  the  technical  difficulty 
of  completely  filUng  it  with  an  opaque  fluid,  it  is  usually 
impossible  to  demonstrate  the  complete  outline  of  the  en- 
tire ureter.     As  a  result  of  the  incomplete  distention  the 


Fig.  40. — Normal  pelvis  and  ureter. 

outline  of  the  ureter  may  appear  more  or  less  irregular. 
The  areas  of  anatomic  narrowing  are  frequently  visible  in 
the  outline  of  the  ureter  a  short  distance  below  the  uretero- 
pelvic juncture,  and  where  the  ureter  enters  the  wall  of  the 
bladder.  The  portion  of  the  ureter  extending  from  the 
true  pelvis  to  the  first  point  of  narrowing  is  usually  more 
fully  distended  and  its  lumen  appears  larger.  It  is  ap- 
parently a  part  of  the  true  pelvis,  from  which  it  tapers 
gradually   to   the   point   of  narrowing.     The  next   visible 


74 


PYELOGRAPHY 


point  of  narrowing  is  where  the  ureter  enters  the  wall  of 
the  bladder,  beyond  which  the  ureteral  lumen  suddenly 
narrows. 

The  course  of  the  normal  ureter  is,  as  a  rule,  fairly  uni- 
form unless  it  is  altered  by  pressure  of  a  stiff  catheter  or 
marked   renal   excursion.     Occasionally   angulation  in   the 


Fig.  41. — Normal  pelvis  and  ureter. 

course  of  the  ureter,  particularly  in  the  first  portion  near 
the  pelvis,  is  visible  without  apparent  reason.  In  Fig.  41 
the  right  ureter  turns  sharply  to  the  right  as  it  leaves  the 
pelvis,  and  then  proceeds  in  an  S-shaped  course.  In  Fig. 
42  a  sinuous  curve  is  noted  in  the  course  of  the  ureter  at 
about  the  ureteropelvic  juncture. 


THE    NORMAL   PELVIS 


75 


Fig.  42. — Normal  pelvis. 


Fig.  43. — Normal  pelvis  and  ureter. 


76  PYELOGRAPHY 

When  the  catheter  is  in  the  ureter,  the  ureteral  outhne 
depends  to  a  great  extent  on  the  degree  of  return  flow  along- 
side the  catheter,  and  on  the  elasticity  of  the  ureteral  wall. 
With  a  profuse  return  flow  the  resulting  outline  may  be 
easily  confused  with  that  of  pathologic  dilatation.  How- 
ever, the  dilatation  occurring  with  pathologic  conditions 
is,  as  a  rule,  more  uniform  and  not  so  irregularly  localized 


Fig.  44. — Normal  pelvis  and  ureter. 

as  with  marked  return  flow  in  the  normal  ureter.  In  Fig. 
43  the  outline  of  the  pelvis  and  ureter  is  normal.  There 
is  but  a  slight  degree  of  return  flow  alongside  the  catheter, 
and  but  little  distention  of  the  ureteral  wall  is  visible. 
Note  the  comparative  large  size  of  the  ureter  from  where 
it  leaves  the  true  pelvis  as  far  as  the  first  point  of  narrow- 
ing. In  Fig.  44  the  degree  of  return  flow  alongside  the 
catheter   is   rendered   clearly   visible   in   the   right   ureter. 


THE    NORMAL    PELVIS 


77 


The  outline  of  the  left  ureter  is  not  visible  because  of  in- 
sufficient distention.  In  Fig.  13  the  irregular  outline  caused 
by  return  flow  is  also  well  illustrated.  In  Fig.  45  the  ure- 
teral outline  is  markedly  irregular  as  the  result  of  profuse 


Fig.  45. — Normal  but  low  pelvis;  normal  but  tortuous  ureter. 


return  flow.     The  course  of  the  ureter  is  tortuous,  because 
of  the  low  position  of  the  kidney. 

The  portion  of  the  ureter  located  in  the  wall  of  the  blad- 
der is  not,  as  a  rule,  outlined  in  the  ureterogram.  An 
opaque  catheter  may  be  visible  in  this  portion  of  the  ureter, 


78  PYELOGRAPHY 

but  the  injected  solution  will  usually  appear  only  in  the  por- 
tion of  the  ureter  above  the  wall  of  the  bladder. 

The  degree  of  elasticity  of  the  normal  ureter  is  frequently 
quite  remarkable.  When  the  ureteral  lumen  is  com- 
pletely occluded  by  the  catheter  and  considerable  pressure 
used  in  introducing  the  fluid,  the  normal  ureter  may  oc- 
casionally become  distended  to  a  width  of  two  or  three 


Fig.  46. — Normal  pelvis  and  ureter. 

centimeters.  As  a  result  of  several  areas  of  partial  occlu- 
sion by  the  catheter,  the  ureteral  outline  may  be  irregular 
and  nodular.  In  Fig.  46  the  upper  ureter  is  apparently 
duplicated  in  a  portion  of  its  course.  The  condition,  how- 
ever, is  the  result  of  the  ureteral  catheter  kinking  in  an 
elastic  and  partially  filled  ureter. 


CHAPTER  IV 

ABNORMAL  POSITION 

The  position  of  the  normal  kidney  is  not  fixed,  and  it 
is  difficult  to  place  any  arbitrary  limits  to  the  extent  of  nor- 
mal change  in  position.  Nevertheless,  a  marked  deviation 
from  the  usual  position  should  be  regarded  as  abnormal. 
Abnormal  position  of  the  kidney  may  be  the  result  of  the 
following  conditions:  (1)  Movable  kidney;  (2)  renal  tor- 
sion;   (3)  dystopic  or  pelvic  kidney. 

MOVABLE  KIDNEY 

As  a  result  of  various  anatomic  conditions,  the  kidney 
may  become  movable,  and  its  position  will  vary,  depending 
upon  the  attitude  assumed  by  the  patient.  Movable  kid- 
ney is  commonly  found  in  the  ill-nourished,  with  lack  of 
tone  in  the  abdominal  muscles  and  a  deficiency  of  perirenal 
fat.  The  condition  is  usually  accompanied  by  functional 
nervous  disturbances  which  are  reflected  by  a  series  of  sub- 
jective symptoms  that  may  render  it  difficult  to  identify  any 
actual  pain  which  might  result  from  renal  excursion.  Defi- 
nite objective  evidence  of  a  pathologic  lesion  as  the  result  of 
the  renal  excursion  is,  therefore,  often  necessary  before  op- 
erative interference  is  indicated.  The  problem  then  arises, 
what  objective  data  are  of  value  in  determining  whether  a 
movable  kidney  should  be  operated  on? 

The  relative  position  and  the  degree  of  excursion  of  the 
two  kidneys  may  be  difficult  to  ascertain  by  means  of  pal- 
pation alone.     These  data,  together  with  the  course  of  the 

79 


80  PYELOGRAPHY 

ureter,  may  be  determined  in  the  radiogram  with  the  as- 
sistance of  the  shadow-casting  catheter.  However,  be- 
cause of  various  technical  reasons,  the  resulting  radiogram 
is  frequently  unsatisfactory  in  determining  the  exact  course 
of  the  ureter  and  in  identifying  the  nature  of  possible  ob- 
struction to  the  ureteral  catheter.  The  pyelogram  offers 
better  means  not  alone  to  show  the  relative  position  of  the 
renal  pelvis  and  the  relation  of  the  pelvis  and  ureter,  but  to 
demonstrate  as  well  the  existence  and  character  of  any 
pathologic  complication.  Frequently  a  second  pyelogram 
with  the  patient  in  the  erect  position  may  be  of  value  in 
order  to  determine  the  comparative  degree  of  renal  excur- 
sion. 

Excursion  in  the  position  of  the  kidneys,  even  though 
marked,  would  give  no  objective  data  for  surgical  inter- 
ference unless  accompanied  by  evidence  of  mechanical  dila- 
tation in  the  pelvis  or  ureter.  It  would  be  difficult  to  con- 
ceive of  the  existence  of  actual  constriction  of  the  ureter  to 
any  definite  degree  without  causing  more  or  less  dilatation 
of  the  ureter  and  pelvis  above  it.  Therefore,  with  both  pelves 
dystopic,  even  though  they  were  situated  as  low  as  the  brim 
of  the  bony  pelvis,  if  neither  of  them  showed  in  their  out- 
line any  evidence  of  mechanical  dilatation,  we  would  have 
no  objective  data  to  warrant  operation.  Further,  if  the 
ureter  showed  angulation  at  any  portion  of  its  course,  even 
though  it  were  well  marked  and  acute,  unless  dilatation  of 
the  ureter  and  pelvis  existed  above  it,  no  objective  data  to 
warrant  surgical  interference  would  be  present.  It  may  be 
conceivable,  however,  that  subjective  data  may  be  so  dis- 
tinct as  to  warrant  an  operation  in  selected  cases.  This 
would  rarely  be  the  case  when  both  renal  pelves  are  found 
to  be  extremely  low. 


ABNORMAL    POSITION 


81 


The  pelvis  of  the  movable  kidney  is  frequently  seen  to 
be  unusually  large,  and  the  calyces  in  particulai*  may  appear 
to  be  distended  and  broader  than  normal.  Occasionally 
the  increase  in  size  is  so  great  as  to  approach  the  border- 
line stage,  where  the  differential  diagnosis  from  actual  hy- 
dronephrosis may  be  difficult.     In  all  probability  the  kid- 


Fig.  47. — Movable  kidney;    abnormal  position  of  kidney. 


ney  assumes  certain  positions,  so  that  the  interference  with 
the  urinary  drainage,  although  not  prolonged  or  marked,  is 
sufficient  slightly  to  dilate  the  pelvis.  In  Fig.  47  the  pelvis 
of  the  right  kidney  is  situated  opposite  the  fourth  lumbar 
vertebra,  just  above  the  crest  of  the  ilium.  It  is  normal  in 
size  and  contour.  Although  there  is  marked  angulation  in 
6 


82  PYELOGRAPHY 

the  ureter  just  below  the  ureteropelvic  juncture,  there  is  no 
evidence  that  it  is  the  cause  of  any  symptoms.  The  local- 
ized irregular  areas  of  evident  dilatation  are  caused  by 
profuse  return  flow.  In  Fig.  19  the  right  pelvis  is  unusu- 
ally low,  being  situated  on  a  level  with  the  crest  of  the 
ilium.  The  caudad  direction  of  the  calyces  shows  that 
the  kidney  was  partially  rotated.  Although  incompletely 
filled,  the  calyces  are  unusually  large  and  probably  slightly 


Fig.  48. — Abnormal  position  of  kidney. 

dilated.  Acute  angulation  of  the  ureter  is  visible  a  short 
distance  below  the  ureteropelvic  juncture.  The  pelvis  of 
the  left  kidney  is  indistinct,  but  its  position  is  seen  to  be 
unusually  low.  In  Fig.  48  the  right  pelvis  is  considerably 
lower  than  the  left.  The  calyces  are  distinctly  broader  and 
more  elongated  than  those  of  the  left  pelvis.  Evidently  a 
temporary  obstruction  has  been  present  and  caused  this 
slight  degree  of  pelvic   dilatation.      In  Fig.   49  the  renal 


ABNORMAL    POSITION 


83 


pelvis  is  situated  at  the  level  of  the  fourth  lumbar  vertebra. 
It  has  rotated  slightly  so  that  the  middle  calyces  extend 
caudad.  The  ureter  has  been  displaced  by  the  lower  pole  of 
the  kidney  so  that  it  overlies  the  fifth  lumbar  vertebra. 
In  Fig.  50  the  right  pelvis  lies  at  a  level  of  the  third  lumbar 
vertebra,  the  left  at  a  level  of  the  second  lumbar  vertebra. 


Fig.  49.— Abnormal  position  of  kidney. 


The  calyces  of  the  right  pelvis  are  evidently  but  partially 
filled. 

The  pelvis  of  the  movable  kidney  may  occasionally  be 
smaller  than  that  of  the  other  kidney.  This  may  be  due  to 
the  fact  that  the  pelvis  is  but  partially  distended  by  the 
injected  fluid.     In  fact,  it  may  be  quite  difficult  to  outline 


84 


PYELOGRAPHY 


Fig.  50. — Abnormal  position  of  kidney. 


Fig.  51. — Kink  in  ureter — otherwise  normal. 


ABNORMAL    POSITION 


85 


fully  the  pelvis  of  the  movable  kidney  because  of  marked  re- 
turn flow,  which  not  infrequently  occurs.  In  Fig.  51  the 
pelvis  is  situated  opposite  the  fouith  lumbar  vertebra.  It 
is  less  than  average  size,  although  the  calyces  are  normal. 
Angulation  of  the  ureter  is  visible  a  short  distance  below 


/^ 


Fig.  52. — Abnormal  position  of  kidney. 

the  ureteropelvic  juncture.  In  Fig.  52  the  right  pelvis  is 
situated  at  the  level  of  the  fourth  lumbar  vertebra,  the  left 
opposite  the  first  and  second  lumbar  vertebrae.  The  right 
pelvis,  although  but  partially  filled,  is  evidently  smaller  than 
the  left  pelvis. 


86 


PYELOGRAPHY 


The  course  of  the  ureter  varies  considerably  with  the 
degree  of  the  renal  excursion.  As  a  rule,  the  course  is 
more  or  less  tortuous  and  may  show  one  or  more  rather 
acute  angles  in  its  course,  which  are  usually  at  or  near  the 
ureteropelvic  juncture.  It  must  be  remembered,  however, 
that  the  course  of  the  ureter  as  seen  in  the  ureterogram  may 
be  greatly  altered  by  the  catheter  within  the  ureter.     The 


Fig.  53. — Abnormal  p()>i(ion  of  the  kidney. 

outline  of  the  ureter  made  by  an  injected  fluid,  as  a  rule,  is 
more  exact  than  the  one  made  by  a  shadow-casting  catheter. 
More  or  less  angulation  of  the  ureter  is  to  be  expected  with 
the  patient  in  the  erect  position.  It  is  of  more  importance 
if  the  angulation  is  present  in  a  dorsal  or  slightly  Trendel- 
enburg position.  In  other  words,  permanent  angulation, 
when  marked  in  spite  of  the  position,  would  be  indicative 
of  possible  obstruction,  particularly  if  evidence  of  dilata- 


ABNORMAL    POSITION 


87 


tion  in  the  pelvis  is  present.  In  Fig.  53  the  right  pelvis  is 
situated  opposite  the  fifth  lumbar  vertebra.  The  calyces 
are  normal,  and  thus  demonstrate  that  no  marked  ureteral 
obstruction  is  present.  The  course  of  the  ureter  is  outlined 
by  the  opaque  catheter.  If  silver  solution  had  outlined 
its  course,  it  would  have  been  more  tortuous  and  would 
not  have  been  displaced  so  far  to  the  left.     In  Fig.  54  marked 


Fig.  54. — Abnormal  position  of  kidney. 

angulation  of  the  ureter  is  visible  a  short  distance  below 
the  ureteropelvic  juncture.  The  dilatation  of  the  ureter 
above  this  point,  as  well  as  the  evidence  of  dilatation  in  the 
calyces,  demonstrates  the  existence  of  actual  obstruction. 
In  Fig.  55  the  right  pelvis  lies  distinctly  lower  than  the  left. 
An  acute  angulation  of  the  right  ureter  may  be  seen  a  short 
distance  below  the  ureteropelvic  juncture,  in  contrast  to 
the  normal  course  of  the  left  ureter.     The  absence,  however. 


88 


PYELOGRAPHY 


Fig.  55. — Abnormal  position  of  kidney. 


Fig.  56. — Abnormal  position  of  the  kidney. 


ABNORMAL    POSITION 


89 


of  any  dilatation  of  the  pelvis  or  calyces  excludes  actual 
obstruction.  In  Fig.  56  the  right  ureter  bends  back  on  it- 
self after  leaving  the  pelvis  in  an  upward  direction.  The  right 
kidney  is  movable  and  the  pelvis  is  situated  at  a  level  of  the 
third  lumbar  vertebra  with  the  patient  in  the  dorsal  position. 
The  normal  outline  of  the  pelvis  excludes  any  pathologic 
obstruction.  In  Fig.  51  the  pelvis  is  situated  low,  even 
though  the  pyelogram  was  made  in  the  dorsal  position. 


Fig.  57. — Movable  kidney. 

The  degree  of  lateral  excursion  of  the  kidney,  when  mov- 
able, is  not,  as  a  rule,  so  apparent  in  the  pyelogram  as  the 
perpendicular.  Occasionally  the  pelvis  is  situated  so  that  it 
lies  in  close  apposition  to,  or  partially  overlying,  the  verte- 
brae. Seldom,  however,  is  it  found  entirely  over  the  ver- 
tebrae. In  Fig.  57  the  pelvis  is  situated  opposite  and 
partially  overlapping  the  third  lumbar  vertebra.     Although 


90  PYELOGRAPHY 

the  general  outline  is  rather  large,  there  is  no  evidence  of 
hydronephrosis.  In  Fig.  49  the  outline  of  the  pelvis  is 
situated  nearer  to  the  vertebrae  than  usual,  as  the  result  of 
slight  lateral  excursion. 

A  comparison  of  pyelograms  made  with  the  patient  in 
the  dorsal  and  erect  positions  may  be  of  value.  On  physical 
examination  one  kidney  only — usually  the  right — may  be 


Fig.  58. — Movable  kidney  (dorsal  posture). 

found  movable.  The  pyelogram  taken  in  the  dorsal  posi- 
tion usually  corroborates  the  abdominal  palpation.  A  sub- 
sequent pyelogram  made  in  the  erect  position  often  shows 
as  great  a  degree  of  mobility  in  the  left  kidney  as  in  the 
right.  In  Fig.  58  (made  in  the  dorsal  position)  the  right 
pelvis  is  situated  but  slightly  lower  than  the  average  pel- 
vis, while  the  position  of  the  left  pelvis  is  normal.  On  ab- 
dominal palpation  the  right  kidney  could  be  plainly  felt  on 


ABNORMAL   POSITION 


91 


respiration,  while  only  the  lower  pole  of  the  left  kidney 
could  be  palpated.  In  Fig.  59  the  pyelogram  was  made 
immediately  after  the  preceding  with  the  patient  in  the 
erect  position.  Both  pelves  are  seen  at  the  level  of  the  crest 
of  the  ilium.     In  order  to  correct  the  anatomic  condition  it 


Fig.  59. — Movable  kidney  (same  as  preceding  in  erect  posture). 

would  be  necessary  to  anchor  both  kidneys.  The  patient's 
subjective  symptoms  were  referred  largely  to  the  right  ab- 
domen, but  the  absence  of  any  dilatation  in  the  pelvis  or 
ureter  and  the  demonstration  of  equilateral  mobility  would 
render  the  advisability  of  operation  doubtful.  A  similar  con- 
dition is  demonstrated  in  Figs.  60  and  61.     On  abdominal 


92 


PYELOGRAPHY 


Fig.  60. — Movable  kidney  (dorsal  posture). 


/ 


% 


> 


<^^' 


Fig.  61. — Movable  kidney  (same  as  preceding,  but  in  erect  posture) 


ABNORMAL   POSITION 


93 


Fig.  62. — Movable  kidney  (dorsal  posture). 


Fig.  63. — Movable  kidney  (same  as  preceding,  but  in  erect  posture). 


94  PYELOGRAPHY 

palpation  the  right  kidney  only  was  easily  felt,  while  in  the 
pyelogram  made  in  the  erect  position  the  excursion  of  both 
kidneys  is  evidently  equal.  In  Figs.  62  and  63  the  excursion 
of  the  right  pelvis  is  much  greater  than  that  of  the  left.  In 
fact,  the  degree  of  excursion  in  the  left  pelvis,  when  out- 
lined in  the  erect  position,  may  be  considered  within  normal 

limits. 

RENAL  TORSION 

Although  the  direction  of  the  calyces  with  movable  kid- 
ney may  be  unusual  because  of  partial  rotation  of  the  kid- 
ney, complete  reversal  of  the  normal  direction  of  the  calyces 
and  of  ureteral  insertion  rarely  complicates  the  ordinary 
movable  kidney.  With  renal  torsion  the  outline  of  the 
renal  pelvis  is  completely  reversed.  Instead  of  the  calyces 
having  in  a  general  way  a  lateral  direction,  they  now  ex- 
tend toward  the  vertebrae.  The  ureter,  instead  of  leading 
toward  and  parallel  to  the  vertebrae,  now  leaves  the  pelvis 
at  the  usual  situation  of  the  lateral  border.  The  position 
of  the  kidney  may  cause  it  to  be  unusually  prominent  on 
abdominal  palpation,  and  might  be  easily  confused  with 
tumor.  Unless  the  position  of  the  other  kidney  is  ascer- 
tained by  means  of  an  opaque  catheter  or  pyelogram,  this 
condition  might  be  confused  with  a  horseshoe  kidney, 
which  may  have  a  similar  arrangement  of  calyces  and  ure- 
ter. 

In  Fig.  64  the  renal  pelvis  is  situated  at  an  unusual  dis- 
tance from  the  vertebral  border.  This  may  be  explained  by 
the  lateral  displacement  of  the  entire  kidney  as  the  result 
of  torsion.  The  true  pelvis  is  unusually  large,  possibly  as 
the  result  of  partial  obstruction.  The  calyces  extend  from 
the  median  border,  instead  of  the  lateral,  as  in  the  normal, 
while  the  ureter  leaves  the  pelvis  from  the  lateral  border  in- 
stead of  the  median. 


ABNORMAL    POSITION  95 

DYSTOPIC  OR  PELVIC  KmNEY 
A  moderate  deviation  from  the  normal  position,  or  even 
a  freely  movable  kidney,  is  not  necessarily  considered  a  con- 
genital anomaly.  When,  however,  the  kidney  is  found  ly- 
ing fixed  to  the  bony  pelvis,  and  when  its  blood-supply 
comes  from  adjacent  arteries,  it  must  be  regarded  as  a  true 


Fig.  64. — Kidney  rotated  on  long  axis.     Large  pelvis. 

congenital  anomaly.  Although  the  relative  position  of  a 
pelvic  kidney  can  frequently  be  ascertained  by  means  of 
the  shadow-casting  catheter,  the  possibility  of  error  when 
the  opaque  catheter  is  otherwise  obstructed  must  always  be 
considered.  Further,  the  position  of  the  kidney  and  its 
relation  to  the  ureter,  as  well  as  any  pathologic  complica- 
tion which  may  be  present,  may  better  be  ascertained  by 
means  of  the  pyelogram.     It  may  be  difficult  to  distinguish 


96 


PYELOGKAPHY 


between  a  low-lying  pelvis  of  a  fused  kidney  and  a  pelvic 
kidney.  As  a  rule,  however,  the  distance  between  the  pelvis 
of  an  ectopic  kidney  and  the  pelvis  of  the  normally  situated 
kidney  will  be  much  greater  than  that  separating  the  two 
pelves  of  a  fused  kidney.  Further,  lateral  or  posterior 
insertion  of  the  ureters  into  the  pelves  would  aid  in  differ- 
entiating the  two  conditions.     The  ectopic  kidney  may  be 


Fig;.  65. — Anomaly  of  the  pelvic  kidney. 

felt  as  a  suprapubic  tumor,  and  it  is  in  the  identification  of 
the  same  that  the  pyelogram  may  disclose  the  condition 
present.  Not  infrequently  will  the  pelvic  kidney  be  un- 
usually small,  and  its  size  would  then  be  suggested  by  that 
of  the  pelvic  outline. 

The  relation  of  the  ureter  to  the  pelvis  in  the  pyelo- 
ureterogram  is  usually  anomalous.  It  leaves  the  pelvis  at 
unusual  angles,  more  often  extending  upward  and  posteriorly 


ABNORMAL   POSITION  97 

before  taking  its  downward  course.  Not  infrequently,  how- 
ever, the  catheter  cannot  be  introduced  into  the  ureter 
of  the  pelvic  kidney  to  its  full  extent  because  of  the  anom- 
alous course  of  the  ureter.  However,  obstruction  to  the 
ureteral  catheter  is  also  frequently  encountered  because  of 
anatomic  and  various  physiologic  conditions  in  the  course 
of  the  ureter  where  the  position  of  the  kidney  is  quite  normal. 
The  pyeloureterogram  would  be  effectual  in  identifying  the 
condition. 

In  Fig.  65  the  pelvis  of  the  dystopic  kidney  is  situated 
opposite  the  lower  portion  of  the  sacrum.  The  outline  is 
small  and  shows  evidence  of  atrophy.  The  course  of  the 
ureter  is  anomalous  in  that  it  leaves  the  pelvis  in  a  prox- 
imal and  lateral  direction.     The  ureter  is  unusually  short. 


CHAPTER  V 
MECHANICAL  DILATATION 

The  renal  pelvis,  as  well  as  the  ureter,  may  become  di- 
lated as  a  result  of  the  following  conditions:  (1)  Mechanical 
obstruction;    (2)  infection;   and  (3)  tumor. 

As  a  result  of  persistent  mechanical  obstruction  to  the 
ureter,  that  portion  above  the  obstruction  and  the  renal 
pelvis  will  become  dilated  to  a  varying  degree.  As  a  result, 
the  outline  of  the  pelvis  and  ureter,  as  seen  in  the  pyelogram, 
will  demonstrate  distinct  deviation  from  the  normal.  The 
dilatation  caused  by  mechanical  obstruction  is  usually  char- 
acterized by  regularity  of  outline  in  contrast  to  the  irregu- 
larity of  inflammatory  or  tumor  dilatation.  The  various 
forms  which  mechanical  dilatation  assumes  may  best  be 
demonstrated  by  describing  the  changes  which  may  be  found, 
first,  in  the  pelvis  (hydronephrosis),  and,  second,  in  the 
ureter  (hydro-ureter). 

THE  PELVIS— HYDRONEPHROSIS 
The  various  changes  in  the  pelvic  outline  resulting  from 
mechanical  obstruction  are  best  described  by  considering 
them  according  to  degree.  As  demonstrated  by  the  pyelo- 
gram, the  following  deviations  from  the  normal  pelvic  out- 
line may  result  from  hydronephrosis : 

1.  Early  hydronephrosis. 

(a)  Flattening  of  terminal  irregularities. 

(b)  Broadening  of  the  base  of  the  calyx. 

(c)  Increase  in  size  of  true  pelvis. 

(d)  Shortening  of  papillae. 

98 


MECHANICAL   DILATATION  99 

2.  Moderate  hydronephrosis. 

(a)  Broadening  of  entire  calyx. 
(6)   Shortening  of  papilla;. 

(c)  Change  in  angle  of  insertion  of  ureter. 

(d)  Increase  in  size  of  pelvis. 

(e)  Changes  of  secondary  infection. 

3.  Large  hydronephrosis. 

(a)  Partially  filled  calyces. 
(6)  Rounded  individual  areas. 

(c)  Single  calyces. 

(d)  Diffuse  outline  of  rounded  sac. 

(e)  Dim  areas  suggestive  of  diluted  opaque 

fluid. 

Early  Hydronephrosis. — In  the  diagnosis  of  hydro- 
nephrosis the  greatest  problem  is  presented  in  definitely 
demonstrating  the  existence  of  early  hydronephrosis  with 
a  capacity  of  from  15  to  25  c.c.  Ordinarily,  with  hydrone- 
phrosis of  moderate  degree  the  demonstration  of  more  or 
less  obstruction  in  the  upper  ureter  by  means  of  the  catheter 
and,  following  this,  the  existence  of  residual  urine  beyond  the 
obstruction,  would  suffice  to  call  our  attention  to  the  prob- 
able existence  of  a  hydronephrosis.  Should  any  doubt  arise, 
the  condition  could  be  further  demonstrated  by  means  of 
the  overdistention  method.  Thus,  if  an  ounce  or  more  of 
fluid  can  be  injected  into  a  renal  pelvis  without  any  evi- 
dence of  return  flow  before  pain  is  caused,  it  may  be  safe 
to  infer  that  hydronephrosis  is  present.  However,  if  on 
distention  a  pelvis  will  hold  from  15  to  25  c.c,  the  question 
arises  are  we  dealing  with  a  pelvis  the  normal  capacity  of 
which  is  from  5  to  10  c.c,  but  which  is  now  dilated  to  two 
or  three  times  its  normal  capacity,  or  with  an  unusually 
large  normal  pelvis?     The  existence  of  a  small  amount  of 


100  PYELOGRAPHY 

residual  urine  in  the  pelvis  might  easily  be  confused  with  the 
rapid  flow  of  hypersecretion.  In  order,  therefore,  to  demon- 
strate the  exact  condition  present,  the  outline  of  a  well- 
distended  pelvis,  as  seen  in  the  pyelogram,  may  be  of  more 
definite  diagnostic  value  than  any  other  data. 

Probably  the  first  deviation  from  the  normal  to  be  noted 
in  the  pyelogram  with  early  hydronephrosis  is  a  flattening 


Fig.  66. — ^Hydronephrosis. 

of  the  terminal  irregularities  seen  in  the  normal  minor 
calyces.  The  apex  of  the  major  calyx  often  becomes  flat- 
tened, and  only  an  occasional  vestige  of  the  minor  calyx 
may  remain.  In  Fig.  No.  66  the  ends  of  the  minor  calyces 
are  seen  to  be  flat.  As  a  result,  the  outline  of  the  calyx 
appears  squared  and  has  been  compared  to  a  "plug  hat." 
Accompanying  the  shortening  of  the  minor  calyx  there  is 
usually  also  a  broadening  of  the  entire  major  calyx.     In  Fig. 


MECHANICAL   D I LATATI O N 


101 


67  the  minor  calyces  are  either  effaced  oi-  inarkfidly  abbre- 
viated. The  major  calyces  are  elongated  and  broadened 
throughout  their  extent,  while  the  true  pelvis  is  but  sHghtly 
dilated.  In  Fig.  68  the  broadening  and  elongation  of  the 
major  calyces  in  the  right  pelvis  are  more  prominent  than 
the  abbreviation   in   the   minor   calyces.     The   changes  in 


Fig.  67. — Hydronephrosis. 


the  minor  calyces  are  due  to  an  increase  in  breadth  rather 
than  to  a  decrease  in  length.  In  Fig.  69  the  broaden- 
ing of  the  major  calyces  is  more  prominent  in  the  upper 
and  lower  calyces.  Several  of  the  minor  calyces  are 
markedly  enlarged,  and  might  even  be  considered  as  sec- 
ondary   major    calyces.     The    terminal    irregularities    are 


102 


PYELOGRAPHY 


Fig.  68. — Hydronephrosis. 


Fig.  69. — Hydronephrosis. 


MECHANICAL   DILATATION  1  Oo 

flattened  and  squared.     The  true  pelvis  is  distinctly  larger 
than  normal. 

Immediately  following  or  accompanying  these  changes 
may  be  noted  an  increase  in  the  size  of  the  true  pelvis. 
With  the  increase  in  size  of  the  pelvis  a  shortening  or  flat- 
tening of  the  papillae  projecting  between  the  major  calyces 
may  be  noted.     Occasionally  the  increase  in  size  of  the  true 


Fig.  70. — Hydronephrosis. 

pelvis  may  be  the  only  apparent  change,  and  the  outline 
of  the  calyces  may  remain  practically  normal.  In  Fig.  70 
the  enlargement  of  the  right  true  pelvis  is  the  predominating 
feature.  The  papillae  usually  projecting  between  the  calyces 
are  almost  effaced,  in  contrast  to  those  in  the  normal  left 
pelvis.  The  major  calyces  are  greatly  abbreviated,  with 
the  exception  of  the  lowest,  which  is  evidently  incom- 
pletely distended.     In  Fig.   71   the  dilatation  in  the  left 


104  PYELOGRAPHY 

true  pelvis  is  the  predominating  feature.  Although  the 
major  calyces  are  probably  not  fully  distended,  they  are 
fairly  well  outlined  and  are  but  slightly  dilated,  while  the 
terminal  irregularities  are  effaced.  The  intercalyx  papillae 
are  unusually  well  preserved. 

Considerable  difficulty  may  be  found  in  differentiating 
the  early  hydronephrosis  from  the  large  normal  pelvis, 
since  the  outline  of  either  the  true  pelvis  or  of  the  major 
calyces  in  a  normal  kidney  is  not  infrequently  of  unusual 


Fig.  71. — Hydronephrosis. 

size.  The  changes  from  the  normal  must  be  well  marked 
in  order  to  identify  a  condition  of  hydronephrosis.  In  Fig. 
72,  although  the  true  pelvis  is  unusually  large,  the  terminal 
irregularities  of  the  minor  calyces  are  normal  and  there  is  no 
broadening  or  elongation  of  the  major  calyces.  The  ab- 
sence of  projecting  papillae  and  the  direct  communication  of 
the  minor  calyces  with  the  true  pelvis  are  unusual.  In  Fig. 
73  the  calyces,  both  major  and  minor,  are  seen  unusually 
broad.  The  terminal  irregularities  are  fairly  well  preserved, 
however,  and   the  papillary  indentations   are  well  defined. 


MECHANICAL    DILATATION 


105 


Fig.  72. — Normal  pelvis. 


Fig.  73. — Normal  pelvis  (border-line). 


106  PYELOGRAPHY 

Hydronephrosis  would,  therefore,  be  excluded.  In  Fig.  74 
the  outline  of  the  upper  and  lower  calyces  is  suggestive  of 
the  broadening  and  flattening  which  accompany  early  hy- 
dronephrosis. However,  the  remaining  calyces  and  the  true 
pelvis  are  quite  normal.  The  peculiar  appearance  of  the 
lower  calyx  is  probably  explained  by  the  shadow  of  an  un- 
derlying secondary  major  calyx.  The  pelvis  must,  there- 
fore, be  considered  normal. 


Fig.  74. — Normal  pelvis. 

In  the  demonstration  of  these  small  hydronephroses  it 
may  be  of  value  to  make  a  bilateral  pyelogram  in  order 
to  compare  the  outlines  of  the  two  pelves.  As  a  rule,  an 
unusual  increase  in  size,  if  normal,  will  appear  bilateral. 
The  outline  of  the  pelvis  on  one  side  appearing  two  or 
three  times  as  large  as  that  on  the  other  should  be 
corroboratory  evidence  of  pathologic  distention.     In  Fig. 


MECHANICAL   DILATATION  107 

68  the  outline  of  the  pelvis  of  the  right  kidney  is  distinctly 
larger  than  that  of  the  left.  Any  doubt  as  to  the  existence 
of  dilatation  in  the  right  pelvis  would  be  excluded  by  com- 
parison of  the  two  pelves.  In  Fig.  71  the  true  pelvis  of  the 
left  kidney  is  seen  to  be  considerably  larger  than  that  of  the 
right.  The  calyces  are  broadened  and  the  terminal  ir- 
regularities  lost   to   some   extent.     On   overdistention   the 


Fig.  75. — Hydronephrosis  (border-line). 

capacity  of  this  pelvis  was  found  to  be  24  c.c.  Such  a 
pyelogram  would  definitely  demonstrate  early  hydrone- 
phrosis and  would  remove  any  question  should  the  diagnosis 
be  first  attempted  by  means  of  the  ureteral  catheter  and 
the  overdistention  method. 

Care  must  be  taken  to  show  the  outhne  of  the  pelvis  of 
the  kidney  fully  distended  in  order  to  demonstrate  these 
early  changes.     If  the  calyces  were  but  partially  filled,  the 


108  PYELOGRAPHY 

normal  terminal  irregularities  of  the  minor  calyces  might 
not  be  shown,  and  with  a  normally  broad  major  calyx  the 
resulting  pyelogram  might  suggest  the  early  changes  of  a 
beginning  hydronephrosis.  Furthermore,  unless  the  pelvis 
is  fairly  well  distended,  the  size  of  the  major  calyces  may 
not  appear  to  be  abnormally  large,  even  in  a  well-marked 
hydronephrosis.     In   Fig.   75  the   true  pelvis  is  evidently 


Fig.  76. — Hydronephrosis. 

partially  filled,  while  the  calyces  are  probably  but  slightly 
distended,  giving  an  erroneous  impression  of  the  exact 
outline.  In  Fig.  76  the  outline  of  the  true  pelvis  is  irregularly 
elongated  and  broadened.  The  calyces  are  narrow,  as 
though  partially  filled,  and  are  well  separated  by  the  flat- 
tened papillae.  In  all  probability,  however,  this  pelvis  is 
not  fully  distended;  otherwise  the  contour  of  the  true  pel- 
vis would  be  more  round  and  more  regular,  and  its  relative 


MECHANICAL   DILATATION  10<» 

size  would  not  be  so  much  greater  than  the  calyces.  The 
difference  in  the  outlines  of  a  partiallj^  and  more  completely- 
filled  hydronephrosis  is  illustrated  in  Figs.  77  and  78.  In 
Fig.  77  the  calyces  appear  as  short,  narrow  streaks,  and 
the  true  pelvis  is  elongated,  but  not  unusually  broad.  Be- 
cause of  marked  ureteral  obstruction,  but  a  small  amount 
of  the  injected  fluid  entered  the  pelvis.     In  Fig.  78  the  out- 


Fig.  77. — Hydronephrosis. 

line  of  the  same  pelvis  is  more  completely  distended,  and 
as  a  result  the  calyces  and  true  pelvis  appear  markedly 
dilated. 

Another  source  of  confusion  in  the  interpretation  of 
changes  subsequent  to  early  hydronephrosis  is  caused  by 
respiration  or  motion  on  the  part  of  the  patient  while  the 
pyelogram  is  being  taken.  In  Fig.  3  (normal  pelvis),  al- 
though the  outline  of  the  true  pelvis  is  not  abnormally 


110  PYELOGRAPHY 

large,  the  minor  calyces  appear  to  be  broadened,  and  their 
outline  is  indistinct  and  blurred.  The  apparent  increase 
in  size  is  explained  by  the  fact  that  the  patient  moved  or 
breathed  at  the  time  the  pyelogram  was  taken. 

A  point  of  interest  in  the  diagnosis  of  hydronephrosis  of 
early  or  moderate  degree  is  the  change  frequently  seen  in 
the  angle  where  the  ureter  leaves  the  pelvis.     The  course 


Fig.  78. — Hydronephrosis. 

of  the  normal  ureter  varies  considerably,  depending  upon 
the  relative  position  of  the  kidney  and  the  first  segment  of 
the  ureter.  As  has  been  previously  stated,  the  angle  formed 
by  the  lower  border  of  the  true  pelvis  and  the  first  portion 
of  the  ureter  is  usually  wide.  With  the  dilatation  of  the 
true  pelvis  it  may,  however,  become  acute.  With  a  low- 
lying  kidney,  otherwise  normal,  the  ureter  may  be  seen 
leaving  the  pelvis  by  a  circuitous  route.     However,  when 


MECHANICAL   DILATATION  Hi 

the  angle  at  the  ureteropelvic  juncture  is  acute,  with  a  dis- 
tinct increase  in  the  size  of  the  pelvis  and  definite  changes 
in  the  outline  of  the  calyces,  the  course  of  the  ureter  may 
be  of  corroboratory  value  in  demonstrating  hydronephrosis. 
In  Fig.  76  the  upper  ureter  is  seen  to  lie  close  to  the  vertebra 
a  short  distance  below  the  ureteropelvic  juncture.  Above 
this  it  is  tortuous  to  the  point  where  it  leaves  the  pelvis. 


Fig.  79. — Hydronephrosis. 

The  contour  of  the  pelvis  is  unusually  elongated,  and  the 
major  calyces  are  suggestive  of  an  incompletely  distended 
early  hydronephrosis.  The  course  of  the  upper  ureter 
may  be  an  etiologic  factor  of  the  distention.  In  Fig.  79 
the  two  large  rounded  shadows  are  the  outlines  of  the  dilated 
calyces  and  demonstrate  the  existence  of  hydronephrosis 
to  a  marked  degree.  Of  particular  interest  is  the  tortuous 
course  of  the  first  third  of  the  ureter  after  leaving  the  pelvis. 


112  PYELOGEAPHY 

In  Fig.  80  the  dilated  calyces  and  dim  outline  of  the  under- 
lying pelvis  are  typical  of  a  large  hydronephrosis.  The 
course  of  the  ureter  as  outlined  by  the  impregnated  catheter 
would  be  impossible.  The  position  of  the  catheter  is  ac- 
counted for  by  the  large  pelvic  sac  in  which  it  is  coiled. 
The  outline  of  the  ureter  itself  is  not  visible. 

Moderate  Hydronephrosis. — With  increase  in  size  of  the 
hydronephrosis  the  major  calyx  is  seen  to  have  become  con- 


Fig.  80. — Hydronephrosis. 

siderably  broader  in  its  entire  extent,  while  the  terminal 
irregularities  will  usually  have  been  effaced.  In  Fig.  81 
the  major  calyces  are  short  and  broadened  throughout, 
while  the  apices  are  squared,  with  the  terminal  irregularities 
effaced.  The  true  pelvis  is  dilated  to  a  considerable  ex- 
tent, and  the  resulting  evenly  curved  border  is  typical  of 
mechanical  distention  in  contradistinction  to  inflammatory 


MECHANICAL   DILATATION 


113 


Fig.  81. — Hydronephrosis. 


837 


Fig.  82. — Hydronephrosis. 


114 


PYELOGRAPHY 


distention.  In  Fig.  82  the  true  pelvis  is  dilated  to  a  mod- 
erate degree.  Although  the  upper  major  calyx  alone  ap- 
pears markedly  broader,  the  other  calyces  are  not  evident 
because  of  insufficient  distention.  At  operation  the  ca- 
pacity of  the  pelvis  was  found  to  be  approximately  120  c.c. 


Fig.  83. — Hydronephrosis. 


In  Fig.  83  the  pelvis  is  situated  on  a  leve]  of  the  fourth 
lumbar  vertebra.  Judging  from  the  caudad  direction  of 
the  calyces,  the  kidney  has  rotated  laterally.  The  true  pel- 
vis is  dilated  and  evenly  rounded  from  mechanical  obstruc- 
tion.    The  major  calyces  are  greatly  enlarged,  and  are  evi- 


MECHANICAL    DILATATION 


115 


dently  narrower  at  the  base.  The  ureter  is  seen  to  be  very 
tortuous  below  the  ureteropelvic  juncture,  and  evidently 
leaves  the  pelvis  posteriorly  and  from  below  instead  of  in 
a  median  direction. 

In  Fig.  84  the  greatly  dilated  major  calyces  are  visible, 
with   a   distinctly   pyramidal   enlargement,    broad    at   the 


Fig.  84. — Hydronephrosis. 


apex  and  narrow  at  the  base.  The  minor  calyces  are  en- 
tirely effaced.  The  outline  of  the  dilated  true  pelvis  is 
suggested  by  a  faint  shadow  underlying  that  of  the  major 
calyces.  The  pelvic  outline  is  dim,  probably  as  a  result  of 
the  dilution  of  the  injected  solution  by  retained  urine.  The 
course  of  the  upper  ureter  is  markedly  tortuous,  and  evi- 


116 


PYELOGRAPHY 


dently  leaves  the  pelvis  posteriorly.     The  position  of  the 
calyces  would  suggest  rotation  of  the  kidney. 

As  the  degree  of  pelvic  dilatation  increases  the  major 
calyces  become  shorter  as  well  as  broader.  The  abbrevia- 
tion of  the  calyx  may  proceed  to  such  an  extent  that  one  or 
two  irregular  indentations  in  the  otherwise  rounded  contour 
of  the  true  pelvis  alone  may  remain.  In  Fig.  85  the  major 
calyces  are  shallow  and  open  widely  at  their  base  into  the 


Fig.  85. — Hydronephrosis. 


lumen  of  the  true  pelvis.  In  Fig.  86  the  outline  of  a  rela- 
tively large  true  pelvis  is  visible.  The  uppermost  calyx  is 
broadened  and  shortened,  while  the  other  calyces  are  sug- 
gested by  irregular  indentation  of  the  general  contour. 

Accompanying  these  changes  in  the  outline  of  the  calyx 
marked  increase  in  the  size  of  the  true  pelvis  will  usually 
The  pelvic  outhne  is  usually  even  and  well  rounded 


occur. 


along  its  free  border,  typical  of  mechanical  distention.     Its 


MECHANICAL    DILATATION 


117 


size  now  makes  it  easily  distinguishable  from  a  very  large 
normal  pelvis.  This  increase  in  size  of  the  true  pelvis  may 
be  out  of  proportion  to  the  more  moderate  changes  seen  in 
the  calyces.  With  increase  in  size  of  the  true  pelvis  the 
papillae,  which  normally  project  between  the  major  calyces 
well  into  the  pelvic  lumen,  become  distinctly  shorter  and 
may  become  so  flattened  as  to  be  practically  effaced.     In 


Fig.  86. — Hydronephrosis. 

Fig.  86  the  papillae  are  reduced  to  mere  indentations  partially 
separating  the  abbreviated  major  calyces. 

In  Fig.  87  the  true  pelvis  is  dilated  greater  in  proportion 
than  the  calyces.  Its  smooth,  round  border  is  typical  of 
mechanical  dilatation.  In  Fig.  88  the  true  pelvis  is  dis- 
tinctly larger  than  normal.  The  calyces  appear  small,  ow- 
ing to  the  fact  that  the  pelvis  is  but  partially  filled.  The 
capacity  of  the  entire  pelvis  would  be  approximately  100  c.c. 


118 


PYELOGRAPHY 


.^ 


■s 


<? 


X 


Fig.  87. — Hydronephrosis. 


Fig.  88. — Hydronephrosis. 


MECHANICAL   DILATATION  119 

Unless  the  pelvis  is  fairly  well  distended,  an  erroneous 
impression  of  the  size  of  the  hydronephrosis  may  be  gained 
from  the  pyelogram.  In  Fig.  89  the  pelvis  appears  dilated 
to  a  moderate  degree.  The  calyces  appear  blurred  and  but 
partially  outhned  because  of  incomplete  distention  by  the 
injected  medium.  At  operation  hydronephrosis  of  over 
150  c.c.  was  found  which  required  nephrectomy. 


Fig.  89. — Hydronephrosis. 

An  element  which  may  affect  the  general  contour  of  the 
dilated  pelvis  is  that  of  secondary  infection.  With  the  in- 
terference to  drainage  secondary  infection  is  frequently 
established,  and,  if  this  goes  on  to  a  considerable  degree, 
it  may  markedly  affect  the  general  pelvic  outhne.  The 
pelvis  may  then  become  more  irregular  in  outline  and  the 
calyces  irregularly  rounded. 

Large     Hydronephroses. — The    demonstration    of    large 


120  PYELOGRAPHY 

hydronephrosis  by  means  of  pyelography  is,  as  a  rule,  un- 
necessary, since  its  existence  may  ordinarily  be  determined 
by  means  of  the  cystoscope  and  ureteral  catheter.  How- 
ever, because  of  the  difficulty  in  interpreting  the  nature  of 
an  obstruction  met  by  the  ureteral  catheter,  or  in  recogniz- 
ing retained  fluid  by  the  usual  cystoscopic  technic,  it  may 


Fig.  90. — Hydronephrosis. 

be  necessary  to  make  a  pyelogram.  It  will  usually  be  diffi- 
cult to  demonstrate  the  entire  contour  of  a  greatly  dis- 
tended pelvis  in  the  pyelogram  because  of  the  dilution  of 
the  injected  medium  by  the  retained  fluid.  The  calyces 
alone  may  be  visible  and  appear  as  detached,  irregularly 
rounded  areas,  particularly  when  partially  filled.  With 
great  dilution  of  a  small  amount  of  injected  solution  either 


MECHANICAL   DILATATIOxV  121 

a  diffuse  round  outline  or  but  a  few  dim,  scattered  shadows 
are  visible  to  suggest  the  distended  sac.  At  times  but  a 
single  dilated  calyx  may  be  outlined,  due  to  the  fact  that 
the  injected  fluid  has  remained  undiluted  in  a  partially 
drained  calyx.  In  Fig.  90  the  outUne  of  a  large  hydro- 
nephrotic  sac  is  visible  with  the  detached  areas  of  greatly 
distended  calyces.     The  ureter  is  seen  to  bend  acutely  upon 


Fig.  91. — Hydronephrosis. 

itself  and  enter  the  pelvis  from  below  the  level  of  the 
sacrum.  In  Fig.  91  the  pelvis  is  but  partially  filled  and  the 
injected  silver  solution  is  unevenly  diluted.  The  true  pelvis 
is  partially  outlined  by  an  irregular  shadow,  which  is  sep- 
arated from  a  number  of  scattered  irregular  shadows  rep- 
resenting the  dilated  calyces.  At  operation,  a  hydro- 
nephrosis of  over  200  c.c.  was  found. 

In  Fig.  92  the  outline  of  the  markedly  dilated  pelvis  and 


122 


PYELOGRAPHY 


Fig.  92. — Hydronephrosis. 


!.45S 


'f 


Fig.  93. — Hydronephrosis. 


MECHANICAL   DILATATION 


123 


calyces  is  suggested  by  a  series  of  irregular  detached  shadows. 
The  size  of  the  normal  pelvis  on  the  other  side  appears  in 
distinct  contrast.  In  Fig.  93  but  a  few  calyces  were  out- 
lined and  appear  as  large  rounded  shadows.  The  injected 
silver  solution  was  so  diluted  by  the  retained  fluid  in  the 


Fig.  94. — Hydronephrosis. 


true  pelvis  that  it  appears  there  as  a  hazy,  diffuse  shadow. 
However,  the  solution  remained  undiluted  in  two  calyces 
which  are  outlined  in  marked  contrast. 

In  Fig.  94  the  pelvis  is  dilated  to  such  an  extent  that  the 
kidney  is  largely  destroyed,  and  in  its  place  is  a  huge  sac. 
Although  the  outline  is  dim  because  of  the  retained  fluid, 


124  PYELOGRAPHY 

it  can  be  seen  to  extend  from  the  last  rib  to  the  crest  of  the 
iUum.  Needless  to  say  that  such  a  pyelogram  is  only  ex- 
ceptionally permissible. 

Pyelography  is  valuable  as  an  aid  to  the  diagnosis  of  hy- 
dronephrosis in  the  following  conditions:  (1)  Constric- 
tion of  the  ureter  not  permitting  a  ureteral  catheter  to  enter 
the  pelvis.  (2)  Short  length  of  catheter  with  return  flow 
on  overdistention.  (3)  Unusual  length  of  catheter  with 
hypersecretion.     (4)  In  demonstrating  etiologic  factors. 

Ureteral  Obstruction. — When  the  obstruction  in  the 
ureter  does  not  permit  the  catheter  to  enter  the  pelvis,  it 
may  be  impossible  to  demonstrate  the  existence  of  a  hydro- 
nephrosis in  any  way  other  than  by  means  of  the  pyelogram. 
It  is  self-evident  that  the  amount  of  residual  urine  could 
not  be  determined,  nor  would  the  overdistention  method 
be  applicable.  While  it  is  probable  that  not  all  the  fluid 
injected  would  pass  the  constriction  and  enter  the  pelvis, 
nevertheless  enough  usually  enters  to  demonstrate  the  out- 
line of  a  hydronephrosis.  It  is  peculiarly  true  that,  while 
even  the  smallest  sound  may  not  pass  certain  constrictions 
in  the  ureter,  fluid  frequently  passes  beyond  the  obstruc- 
tion. Figs.  77  and  78  show  an  elongated,  partially  filled 
pelvis  with  the  calyces  incompletely  distended.  While 
but  little  of  the  solution  entered  the  pelvis,  enough  was 
present  to  demonstrate  the  condition.  The  catheter  met 
with  an  impassable  obstruction  at  the  ureteropelvic  junc- 
ture. In  Fig.  93  the  catheter  extends  as  far  as  an  impassable 
constriction  in  the  ureter  at  about  the  level  of  the  lower 
border  of  the  fourth  lumbar  vertebra.  Consequently,  no 
estimate  of  the  residual  urine  could  be  made.  The  ureter 
above  this  point  is  but  moderately  dilated,  while  dilatation 
of  the  pelvis  is  extensive. 


MECHANICAL    DILATATION  125 

Not  infrequently  an  unusually  short  length  of  catheter 
passes  up  into  the  ureter,  and,  upon  injecting  the  fluid, 
there  is  a  rapid  return  flow.  This  may  occur  in  the  normal, 
low-lying  kidney  as  the  result  of  actual  constriction  of  the 
upper  ureter  because  of  pathologic  conditions,  or  because 
of  kinking  in  the  ureter  due  to  various  anatomic  conditions 
in  its  course.  The  pyelogram  will  demonstrate  the  exist- 
ence of  a  dilatation  in  the  ureter  or  in  the  pelvis  above  such 
obstruction  and  so  determine  whether  it  is  actually  the  re- 
sult of  pathologic  conditions  or  merely  anatomic. 

Unusual  Length  of  Catheter. — Occasionally  there  is  a 
combination  of  unusual  length  of  catheter  inserted  into 
the  ureter,  accompanied  by  a  rapid  secretion  suggestive 
of  residual  urine.  The  combined  data  might  easily  be  re- 
garded as  due  to  hydronephrosis.  It  is  well  known  that 
with  a  large  normal  pelvis  and  plastic  ureter  a  soft  ureteral 
catheter  may  be  coiled  up  to  unusual  lengths,  and,  further, 
that  not  infrequently  a  very  rapid  secretion  from  the  kid- 
ney may  occur  as  the  result  of  reflex  u-ritation.  A  pyelo- 
gram taken  under  such  conditions  would  demonstrate  the 
exact  condition  present  and  would  exclude  an  erroneous 
diagnosis  of  hydronephrosis. 

Etiologic  Factors. — A  pyelogram  may  be  of  considerable 
value  when  demonstrating  the  etiologic  factors  present. 
Of  particular  value  is  its  power  to  demonstrate  whether  the 
obstruction  is  in  the  upper  or  lower  ureter,  whether  pri- 
marily or  secondarily  inflammatory,  whether  due  to  change 
in  the  position  of  the  kidney,  whether  caused  by  anatomic 
and  pathologic  conditions  in  the  surrounding  structures, 
and,  lastly,  it  not  infrequently  tells  us  the  nature  of  the  ob- 
struction, particularly  when  subsequent  to  a  constricting 
anomalous  renal  blood-vessel. 


126  PYELOGRAPHY 

Mobility  of  the  kidney  is  generally  believed  to  be  the 
most  common  cause  of  hydronephrosis.  At  operation, 
however,  the  majority  of  hydronephroses  are  not  found  in 
low-ljdng  or  freely  movable  kidneys.  That  hydronephrosis 
does  occur  where  marked  mobility  and  angulation  of  the 
ureter  are  the  only  evident  etiologic  factors  is  evident  in 
Fig.  83.  The  right  pelvis  is  situated  so  low  that  the  calyces 
extend  to  the  crest  of  the  ilium.  The  ureter,  as  outlined 
by  the  catheter,  apparently  leaves  the  pelvis  in  a  circuitous 
manner.  The  outline  of  the  dilated  calyces  and  pelvis 
demonstrates  the  existence  of  mechanical  obstruction.  At 
operation  no  constricting  tissue  was  found  to  cause  the 
ureteral  obstruction. 

That  the  etiologic  factor  in  hydronephrosis  and  conse- 
quent pyelitis  found  in  pregnancy  is  due  to  pressure  on  the 
ureter  by  the  uterus  may  be  inferred  from  the  pyelo-uretero- 
gram.  The  ureter,  and  in  varying  degree  the  renal  pelvis, 
may  be  seen  dilated  above  the  point  of  constriction,  which 
is  usually  in  its  middle  or  lower  third  portion.  Not  infre- 
quently the  resultant  dilatation  will  have  the  character- 
istics of  both  mechanical  and  inflammatory  etiology.  It 
appears  that  in  practically  every  case  of  pyelitis  with  preg- 
nancy the  interference  with  drainage  and  urinary  retention 
is  the  cause  of  the  infection.  That  such  dilatations  may 
disappear  rather  slowly  is  shown  by  pyelograms  taken 
several  months  or  even  years  following  labor.  When  the 
infection  of  the  entire  kidney  does  not  disappear  with  the 
resumption  of  drainage,  the  process  may  become  one  of 
pyonephrosis. 

Not  infrequently  constriction  in  the  lower  ureter  may  be 
missed  by  the  inserted  ureteral  catheter,  and  it  might  be 
inferred,  from  the  residual  urine  in  the  pelvis,  that  we  are 


MECHANICAL    DILATATION  127 

dealing  with  a  hydronephrosis  with  the  usual  upper  ureteral 
constriction.  Exploration  through  a  lumbar  incision  would 
disclose  the  actual  condition  with  difficulty.  However,  if 
in  the  pyelo-ureterogram  the  ureters  are  seen  dilated  above 
the  point  of  low  obstruction,  the  incision  would  be  governed 
accordingly.  With  obstruction  in  the  lower  ureter  the 
degree  of  dilatation  in  the  pelvis  usually  is  relatively  less 
than  that  in  the  ureter.  Further,  with  low  ureteral  ob- 
struction, the  distention  of  the  pelvis  of  the  kidney  is  pre- 
dominantly in  the  calyces  and  secondarily  in  the  true  pelvis. 
In  fact,  a  rule  might  well  be  made  that  the  relative  disten- 
tion of  a  calyx  and  pelvis  varies  with  the  level  of  the 
ureteral  obstruction.  With  the  obstruction  in  the  upper 
ureter,  the  true  pelvis  will  distend  to  a  greater  degree  than 
the  calyx,  whereas  the  situation  is  reversed  when  the  ob- 
struction is  low.  With  obstruction  in  the  lower  ureter, 
broadening  of  the  ureter  and  that  portion  of  the  pelvis  ad- 
jacent to  the  ureteropelvic  juncture  may  usually  be  dem- 
onstrated. This  may  be  of  considerable  value  in  the  rec- 
ognition of  moderate  hydronephrosis.  In  Fig.  95  the 
calyces  are  dilated  in  a  manner  which  is  typical  of  mechan- 
ical obstruction  in  the  lower  ureter.  They  are  broad  at 
the  apices,  which  gives  them  a  triangular  shape.  The 
pelvis  is  but  slightly  enlarged.  The  extent  of  ureteral  di- 
latation is  not  completely  shown  because  of  insufficient 
distention. 

Not  infrequently,  secondary  infection  occurs  in  the 
original  hydronephrosis.  In  such  cases  the  clinical  and  cys- 
toscopic  data  may  be  masked  by  that  of  secondary  infec- 
tion, and  the  existence  of  a  purely  inflammatory  process 
may  be  suspected.  With  the  greater  enlargement  in  the 
calyces  and  with  irregularity  of  the  general  pelvic  outline 


128  PYELOGKAPHY 

a  primary  inflammatory  etiology  would  be  inferred.  With 
the  distention  predominating  in  the  true  pelvis  and  char- 
acterized with  more  or  less  regularity  of  outline  the  original 
mechanical  etiology  would  be  demonstrated.  Occasionally, 
however,  it  is  difficult  to  determine  from  the  pelvic  outline 
whether  the  inflammatory  or  mechanical  influence  was 
primary.     With  marked  inflammatory  changes  in  the  pelvic 


V 


Fig.  95. — Hydronephrosis. 

outline  the  original  mechanical  factor  may  be  obscured, 
and  the  probability  of  original  hydronephrosis  may  be  as- 
certained only  by  means  of  subjective  symptoms.  Thus 
in  Fig.  96  evidence  of  both  factors  is  present.  The  true 
pelvis  is  markedly  dilated,  as  with  mechanical  obstruction. 
The  irregular  outline  of  the  calyces  would  suggest  the  in- 
fluence of  secondary  infection.  In  Fig.  97  the  calyces  are 
broadened  and  the  minor  calyces  effaced,  causing  the  end 


MECHANICAL    DILATATION  129 


Fig.  96. — Hydronephrosis — infected. 


Fig.  97. — Hydronephrosis — infected. 


130  PYELOGRAPHY 

of  the  calyx  to  be  flattened.  However,  the  general  contour 
of  the  calyces  is  irregularly  rounded  and  the  ureter  shows 
moderate  irregular  dilatation,  both  of  which  are  the  result 
of  infection.  The  condition  is  an  infected  early  hydro- 
nephrosis. 

Occasionally  it  may  be  of  practical  value  to  determine 
clinically  the  actual  cause  of  the  constriction  of  the  upper 
ureter.  A  contour  of  the  hydronephrotic  sac  has  been  fre- 
quently noted  peculiar  to  constriction  caused  by  an  anom- 
alous renal  blood-vessel.  The  majority  of  anomalous 
blood-vessels  which  constrict  the  upper  ureter  enter  the 
lower  pole  of  the  kidney.  In  doing  so  they  cross  the  ureter 
several  centimeters  below  the  ureteropelvic  juncture.  In 
the  subsequent  dilatation  the  pelvis  dilates  to  a  greater  ex- 
tent than  the  upper  ureter.  Consequently  the  general 
contour  of  the  resulting  sac  will  be  pyriform.  In  Fig.  86 
the  general  contour  of  the  pelvis  is  irregularly  pyriform. 
The  upper  ureter  is  distinctly  dilated  to  a  short  distance 
below  the  ureteropelvic  juncture,  at  which  point  an  anom- 
alous blood-vessel  was  found  to  constrict  the  ureter.  In 
Fig.  85  the  outline  of  the  true  pelvis  tapers  toward  the 
ureteropelvic  juncture  slightly  below  which  an  anoma- 
lous blood-vessel  was  found  at  operation  to  constrict  the 
ureter. 

Scoliosis  may  be  a  factor  in  the  production  of  hydro- 
nephrosis, with  subsequent  change  in  the  position  of  the 
kidney.  Pressure  by  extra-ureteral  organs  or  tissues  may 
be  the  cause  of  hydronephrosis,  particularly  as  the  result 
of  pathologic  conditions  in  the  female  pelvis.  The  ure- 
teral dilatation  extending  down  as  far  as  the  condition  in 
question  would  determine  the  etiology. 

Persistence   of   Colloidal  Silver. — In  cases  in  which  the 


MECHANICAL   DILATATION  131 

results  of  examinations  are  unsatisfactory  and  the  existence 
of  a  hydronephrosis  is  in  doubt,  evidence  of  the  persistence 
in  the  pelvis  of  the  injected  substance  may  be  of  value  in  the 
diagnosis.  Under  normal  conditions  all  evidence  of  col- 
loidal silver  in  the  urine  should  be  absent  in  less  than 
twenty-four  hours  after  the  injection.  Normally,  no  evi- 
dence of  the  injected  solution  (colloidal  silver)  is  visible  in  a 


Fig.  98. — Hydronephrosis — injected  solution  retained. 

radiogram  taken  twenty-four  hours  after  the  pyelogram.  In 
Fig.  98  a  small  irregular  shadow  is  visible  which  represents 
the  silver  solution  remaining  in  a  normal  pelvis  two  and 
one-half  hours  after  a  pyelogram  was  made.  If  the  urine 
remains  stained  for  several  days  following,  we  have  evi- 
dence of  retention  in  some  portion  of  the  urinary  tract.  If 
a  subsequent  radiogram  is  taken  twenty-four  hours  after 
the  injection  and  the  shadows  of  the  retained  injected  solu- 


132  PYELOGRAPHY 

tion  are  evident,  the  nature  of  the  retention  will  be  apparent. 
The  outline  of  the  ends  of  distended  calyces  which  are  but 
partially  drained  may  remain  for  several  days  following  the 
pelvic  injection.  In  case  of  a  large  distention  a  diffuse, 
dim  shadow  of  irregular  density  made  faint  by  dilution  may 
persist  for  a  varying  length  of  time. 

Post-operative   Course. — Of  considerable  interest  is  the 
course  of  the  hydronephrotic  sac  following  the  removal  of 


Fig.  99. — Hydronephrosis. 

the  ureteral  obstruction  at  operation.  If  distention  has 
not  been  too  great,  and  if  there  is  no  marked  degree  of  sec- 
ondary infection,  the  sac  may  approximately  resume  its 
normal  contour  in  the  course  of  time.  In  Fig.  85  a  plastic 
operation  was  made  three  years  ago  and  since  then  the 
patient's  subjective  symptoms  were  relieved.  A  pyelo- 
gram  recently  made  shows  the  pelvis  practically  normal  in 


MECHANICAL   DILATATION  133 

outline,  and  with  a  capacity  of  28  c.c.  In  Fig.  99  the 
calyces,  particularly  the  lower,  are  slightly  dilated.  This 
plate  was  made  three  months  after  labor,  prior  to  which 
the  patient  had  pyelitis  of  pregnancy  and  a  small  h3'dro- 
nephrosis  on  the  right  side.  It  is  clearly  shown  that  the 
mechanical  dilatation  is  almost  effaced  following  the  re- 
moval of  the  etiologic  factor.  On  the  other  hand,  the  outline 
of  well-marked  hydronephroses  frequently  may  not  become 


Fig.  100. — Hydronephrosis — postoperative. 

normal,  but  remain  more  or  less  dilated  even  though  the  drain- 
age is  restored.  As  a  rule,  if  the  pelvis  then  remains  dilated 
it  is  because  of  cicatricial  changes  in  the  walls  of  the  pelvis, 
the  result  of  inflammation.  In  Fig.  100  the  calyces  and  the 
pelvis  are  dilated  to  a  moderate  degree.  Three  years  prior  a 
plastic  operation  was  made  on  the  kidney  for  hydronephro- 
sis. Since  the  operation  the  patient  was  subjectively  cured. 
Cystoscopic  examination  now  shows  the  renal  function  to 


134  PYELOGRAPHY 

be  approximately  normal  despite  the  fact  that  the  pelvis 
did  not  resume  the  normal  shape. 

Intrarenal  Hydronephrosis. — Although  usually  hydro- 
nephrosis is  characterized  by  marked  distention  of  the  true 
pelvis,  occasionally  the  dilatation  may  be  confined  largely 
to  the  calyces.  This  type  of  hydronephrosis  has  been 
termed  intrarenal.     On  section  of  the  kidney  the  calyces 


Fig.  101. — Hydronephrosis — intrarenal. 

will  be  found  to  be  so  markedly  distended  that  they  often 
extend  to  the  very  limits  of  the  cortex,  while  the  distention 
of  the  true  pelvis  is  largely  confined  within  the  substance 
of  the  kidney.  The  parenchyma  of  the  kidney  will,  as  a 
result,  be  considerably  atrophied  and  limited  in  extent. 
Intrarenal  distention  of  the  pelvis  may  often  be  explained 
by  a  peripyelitis  with  subsequent  cicatricial  tissue  which 
prevents  extrarenal  dilatation.     This  intrarenal  type  of  dis- 


MECHANICAL    DILATATION  135 

tention  is  illustrated  in  Fig.  101.  The  dilated  calyces  are 
made  apparent  by  a  nodular  group  of  shadows  which  out- 
line their  dilated  apices.  The  true  pelvis  is  suggested  by 
a  dim,  diffuse  shadow.  A  similar  pyelogram  may  result, 
however,  when  the  injected  fluid  becomes  so  diluted  in  the 
dilated  true  pelvis  that  its  actual  extent  is  not  seen  in  the 
pyelogram,  while  the  outline  of  the  calyces  may  be  defined. 
Functional  Estimate. — An  estimate  of  the  functional 
capacity  of  the  kidney  may  frequently  be  made  by  the 
character  and  size  of  the  outline  of  the  pelvis.  When  the 
pelvis  is  demonstrated  to  be  a  large  sac  with  a  capacity  of 
five  or  six  ounces  or  more,  and  when  the  calyces  are  seen  to 
be  greatly  dilated  and  extending  well  into  the  cortex,  usu- 
ally comparatively  little  functionating  tissue  remains.  In 
such  cases  the  plastic  operation  will  not,  as  a  rule,  prove 
successful,  and  nephrectomy  is  indicated. 

THE  URETER— HYDRO-URETER 
Distention  of  the  ureter  because  of  mechanical  obstruc- 
tion, or  hydro-ureter,  may  vary  considerably  in  degree. 
It  is  usually  greatest  with  marked  obstruction  of  long  stand- 
ing. The  degree  of  dilatation  accompanying  mechanical 
obstruction  is  usually  greater  than  that  accompanying  in- 
flammatory changes.  With  obstruction  in  the  lower  ureter, 
particularly  if  recent,  the  adjacent  ureter  will  dilate  to 
a  greater  degree  than  the  upper  portion.  The  dilatation 
of  the  pelvis  may  then  be  so  slight  that  it  is  recognized  with 
difficulty.  With  low  ureteral  obstruction  the  dilatation  in 
the  pelvis  will  be  largely  confined  to  the  calyces.  In  Fig. 
95  the  dilated  calyces  resulted  from  obstruction  in  the  lower 
ureter.  A  peculiarity  occasionally  noted  with  obstructions 
of  long  standing  at  the  wall  of  the  bladder  is  that  the  por- 


136  PYELOGRAPHY 

tion  of  the  ureter  extending  from  the  ureteropelvic  juncture 
to  the  first  point  of  narrowing  may  remain  but  shghtly 
dilated,  while  the  ureter  below  and  the  pelvis  above  are 
considerably  dilated.  Ureteral  obstruction  is  commonly 
caused  by  tuberculosis,  lithiasis,  congenital  conditions,  ex- 
ternal pressure,  cicatricial  constriction,  or  urinary  obstruc- 
tion. The  pyelo-ureterogram  will  not  infrequently  be  of  aid 
in  determining  the  etiologic  factor  present  when  the  usual 
methods  of  examination  have  failed. 

With  renal  tuberculosis  the  only  subjective  symptom 
may  be  severe  renal  colic,  and,  on  cystoscopic  examination, 
obstruction  to  the  ureteral  catheter  may  be  the  only  evi- 
dence of  a  pathologic  condition.  In  the  pyelo-ureterogram 
the  ureter  will  appear  uniformly  dilated  from  the  uretero- 
pelvic juncture  to  the  point  of  stricture,  where  it  tapers 
sharply.  The  outline  of  the  dilated  pelvis  will  differ  from 
the  usual  hydronephrosis  in  that  the  inflammatory  element 
predominates.  The  dilatation  in  the  calyces  will  be  com- 
paratively greater  than  in  the  true  pelvis,  and  will  be  very 
irregular.  The  character  of  the  dilatation  above  the  point 
of  constriction  in  both  ureter  and  pelvis  will  usually  suffice 
to  identify  the  tubercular  etiology.  In  Fig.  102  the  ureter 
is  dilated  above  a  point  of  slight  obstruction  to  the  catheter 
in  its  lower  portion.  The  irregular  inflammatory  changes 
in  the  pelvic  outline  are  suggestive  of  tissue  necrosis  which 
occurs  only  with  tuberculosis. 

Not  infrequently  a  small  stone  in  the  lower  ureter  fails 
to  be  outlined  in  a  radiogram,  particularly  if  situated  in  the 
area  of  the  bony  pelvis.  On  cystoscopic  examination  more 
or  less  obstruction  may  be  noted  by  the  ureteral  catheter. 
If  the  ureterogram  shows  the  ureter  to  be  dilated  at  or 
above  this  point,  the  possibility  of  stone  must  be  inferred 


MECHANICAL   DILATATION  137 

in  the  absence  of  tuloercle  })acilli  or  abdominal  tumor.  In 
Fig.  103  the  original  radiogram  was  negative  for  stone. 
The  catheter  met  with  slight  obstruction  in  the  lower  ureter 
opposite  the  brim  of  the  pelvis,  which  was  readily  passed. 
The  pyelo-ureterogram  shows  the  ureter  uniformly  dilated 


Fig.  102. — Hydro-ureter — tuberculosis. 

above  the  point  of  ureteral  obstruction  as  far  as  the  renal 
pelvis.  In  Fig.  104  the  outline  of  the  pelvis  shows  the 
terminal  irregularities  flattened  and  the  ends  of  the  calyces 
slightly  squared,  as  may  frequently  be  seen  with  early 
mechanical  dilatation.     At    operation  a  very  small   stone 


138 


PYELOGRAPHY 


%*.: 


Fig.  103. — Hydro-ureter. 


Fig.  104. — Hydronephrosis  and  hydro-ureter. 


MECHANICAL   DILATATION 


139 


was  found  in  the  ureter  at  the  site  of  constriction  which  had 
caused  ulceration  and  edema  in  the  mucosa  of  the  ureter  at 
the  second  point  of  narrowing. 

Tumor  in  the  lower  abdomen,  and  particularly  in  the 
female  pelvis,  is  often  found  to  constrict  the  lower  ureter 
and  cause  more  or  less  dilatation.  The  ureter  usually  re- 
sumes an  approximately  normal  size  after  the  tumor  is  re- 


'  ^Bm 


Fig.  105. — Ureteral  dilatation,  right  side.     Left  pelvis  and  ureter  normal. 

moved  and  requires  no  surgical  interference.  In  Fig.  105 
the  ureter  is  dilated  above  the  level  of  the  crest  of  the  ilium 
and  is  markedly  tortuous.  The  irregular  shadows  are  ex- 
plained by  partial  distention  of  the  markedly  dilated  ureter 
and  dilution  of  the  injected  medium  by  retained  fluids. 
The  outline  of  the  dilated  pelvis  is  suggested  by  hazy 
shadows.     At  operation  a  tumor  in  the  right  broad  liga- 


140 


PYELOGRAPHY 


ment  was  found  causing  pressure  on  the  ureter,  but  not  in- 
volving it.  In  Fig.  95  the  dilated  calyces  were  caused  by 
a  pelvic  tumor  pressing  on  the  ureter. 

Various  chronic  conditions,  such  as  stricture  at  the  meatus, 


Fig.  106. — Hydro-ureter  and  hydronephrosis. 


ureterocele,  and  atonic  dilatation  of  the  ureter,  are  usually 
accompanied  by  marked  distention  of  the  ureter.  In  Fig. 
106  a  large  ureterocele  was  found  on  cystoscopic  examina- 
tion. Its  outline  is  visible  in  the  pyelo-ureterogram  at  the 
caudad  end  of  the  ureter.     The  ureter  is  markedly  dilated 


Fig.  107. — Hydro-ureter. 


Fig.  108. — -Hydronephrosis  and  hydro-ureter. 
141 


142  PYELOGRAPHY 

throughout  and  tapers  gradually  toward  the  renal  pelvis. 
The  pelvic  dilatation  is  moderate  in  degree  and  in  character 
is  both  mechanical  and  inflammatory.  In  Figs.  107  and 
108  the  right  ureter  is  dilated  markedly  from  the  meatus 
to  the  renal  pelvis.  It  is  tortuous  and  narrower  at  the  por- 
tion extending  from  the  pelvis  to  the  first  point  of  narrow- 
ing.    The  dilatation  in  the  pelvis  is  predominatingly  in  the 


Fig.  109. — Stricture  of  ureter  at  bladder. 

calyces,  as  is  customary  with  obstruction  in  the  lower  ureter. 
No  actual  obst  ruction  was  found  at  the  meatus  by  the  ure- 
teral catheter.  The  condition  is  evidently  one  of  congenital 
atonic  dilatation. 

Cicatricial  constriction  usually  follows  ulceration  of  the 
ureteral  mucosa  by  infection  or  trauma.  It  is  more  com- 
monly found  in  the  lower  portion  of  the  ureter.  It  is  oc- 
casionally found  together  with  a  small  stone  lodged  in  the 


MECHANICAL    DILATATION  143 

ureter  or  as  the  result  of  trauma  following  its  passage.  In 
Fig.  109  the  ureter  is  markedly  dilated  above  the  wall  of 
the  bladder  for  a  distance  of  3  cm.  Above  this  point  the 
ureter  is  incompletely  distended.  At  operation  dilatation 
of  the  ureter  was  found  which  was  evidently  the  result  of 
an  inflammatory  constriction  of  the  ureter  at  the  wall  of 
the  bladder. 

Dilatation  of  both  ureters  may  result  from  stricture  of 
the  urethra  or  prostatic  obstruction  which  also  causes 
marked  dilatation  of  the  bladder.  The  meati  are  gaping 
and  the  ureters  may  be  outlined  in  part  by  filling  the  bladder 
with  an  opaque  medium  and  allowing  it  to  gravitate  into 
the  ureter  while  the  patient  is  in  the  Trendelenburg  posi- 
tion. More  often,  however,  ureteral  dilatation  with  pros- 
tatic hypertrophy  is  the  result  of  inflammatory  changes  in 
the  ureteral  wall. 

Stricture  of  the  ureter  may  occur  which  obstructs  the 
ureteral  lumen  at  intervals  only  temporarily,  and  it  is  possi- 
ble that  the  ordinary  method  of  cystoscopic  examination 
may  fail  to  disclose  the  presence  of  stricture  when  examined 
during  the  interval  of  patency.  A  ureterogram  may  be  of 
considerable  value  in  such  cases  and  may  be  the  only  method 
by  which  the  condition  can  be  demonstrated.  Further, 
even  though  the  existence  of  a  stricture  is  ascertained  by 
means  of  the  ureteral  catheter  alone,  its  extent  and  the  de- 
gree of  dilatation  above  it  can  frequently  be  ascertained 
more  accurately  by  means  of  the  pyelo-ureterogram. 

When  encountering  obstruction  to  the  ureteral  catheter 
considerable  difficulty  may  arise  in  differentiating  between 
an  anatomic  and  a  pathologic  condition.  The  catheter  may 
meet  with  obstruction  at  any  level  of  the  ureter,  as  the  re- 
sult of  some  anatomic  condition,  such  as  acute  angulation 


144  PYELOGRAPHY 

in  the  course  of  the  ureter,  marked  elasticity  of  the  ureteral 
wall,  or  a  loose  mesenteric  attachment.  In  most  of  these 
conditions  an  injected  fluid  will  pass  any  obstruction  offered 
to  the  ureteral  catheter,  and  the  absence  of  dilatation  or  any 
evidence  of  abnormality  will  demonstrate  the  anatomic 
nature  of  the  obstruction.  On  the  other  hand,  an  immediate 
return  flow  of  the  injected  fluid  would  suggest  a  pathologic 
condition.  Occasionally,  however,  with  anatomic  obstruc- 
tion of  the  ureteral  catheter  just  beyond  the  meatus,  im- 
mediate return  flow  may  also  be  present.  With  pathologic 
obstruction,  when  the  fluid  gets  by,  a  nodular  dilatation 
about  the  obstruction  or  diffuse  dilatation  above  it  will  be 
visible. 

With  marked  dilatation  of  the  ureter  above  an  obstruc- 
tion the  retained  fluid  may  dilute  the  injected  fluid  to  such 
a  degree  that  the  outline  of  the  distended  ureter  may  be- 
come indistinct.  Occasionally  only  that  portion  of  the 
dilated  ureter  which  extends  a  short  distance  above  the 
obstruction  will  be  visible  in  the  ureterogram.  No  evi- 
dence of  the  injected  medium  may  be  visible  in  the  pelvis 
except  in  the  apices  of  one  or  more  dilated  calyces. 


CHAPTER  VI 

INFLAMMATORY  DILATATION 

Any  considerable  degree  of  infection  involving  the  renal 
pelvis  and  ureter  will  be  followed  by  dilatation.  This  dila- 
tation is  not  caused  by  mechanical  obstruction,  but  is  the 
result  of  change  in  the  tissues  and  consequent  retraction 
in  the  walls  of  the  pelvis  and  ureter.  The  dilatation  ma}^ 
vary  from  a  scarcely  recognizable  irregularity  of  the  calyces 
or  ureter  to  complete  destruction  of  the  pelvis.  Evidence 
of  an  inflammatory  process  which  has  once  caused  dilata- 
tion will  rarely  be  entirely  obliterated.  Such  inflammatory 
changes  in  the  pelvic  or  ureteral  outline  may  be  the  only 
evidence  of  previous  infection.  The  character  and  degree 
of  an  inflammatory  process  can  often  be  determined  better 
by  means  of  the  pyeloureterogram  than  by  any  other  method. 

THE  PELVIS  (PYELITIS;  PYONEPHROSIS) 
Dilatation  of  the  renal  pelvis  as  the  result  of  inflamma- 
tory changes  in  its  walls  differs  from  mechanical  dilatation 
largely  in  the  following  characteristics:  (1)  General  ir- 
regularity of  outline;  (2)  predominance  of  dilatation  in  the 
calyces  rather  than  in  the  true  pelvis;  (3)  clubbing  and 
rounding  of  the  ends  of  the  calyces.  It  will  be  found  that 
infections  predominant  in  the  renal  pelvis  are  usually  ac- 
companied by  a  considerable  degree  of  inflammatory  dila- 
tation, whereas  infections  predominant  in  the  renal  par- 
enchyma usually  cause  but  slight  inflammatory  changes  in 
the  pelvic  outline. 

10  145 


146 


PYELOGRAPHY 


The  changes  more  commonly  found  in  the  outhne  of  the 
renal  pelvis  as  the  result  of  an  inflammatory  process  are  as 
follows:  (1)  Dilatation  predominant  in  the  calyces;  (2) 
dilatation  predominant  in  the  true  pelvis;     (3)   dilatation 


Fig.  110. — Inflammatory  dilatation. 


involving  entire  pelvis;  (4)  pyonephrosis;  (5)  dilatation 
predominant  in  the  ureter;  (6)  alternating  contraction  and 
dilatation;    (7)  atrophy. 


INFLAMMATORY    DILATATION  147 

I.  Dilatation  Predominant  in  the  Calyces. — The  earliest 
changes  in  the  pelvic  outline  as  a  result  of  infection  are  com- 
monly characterized  by  slight  broadening  and  irregular 
rounding  of  the  calyces,  with  scarcely  recognizable  changes 
in  the  true  pelvis.  A  moderate  uniform  dilatation  of  the 
ureter  may  be  of  importance  in  the  recognition  of  early 


Fig.  IIL — Inflammatory  dilatation. 

changes.  In  Fig.  110  the  major  calyces  are  slightly  clubbed 
and  rounded  at  the  apices,  while  the  minor  calyces  are 
effaced.  The  true  pelvis  remains  normal  in  outline  and 
size.  The  ureter  is  moderately  dilated  in  its  entire  extent 
and  is  tortuous  as  far  as  the  first  point  of  narrowing. 

As  the  inflammatory  process  progresses  the  dilatation  in 
the  calyces  may  become  well  marked,  while  little  or  no  dila- 


148  PYELOGRAPHY 

tation  may  be  apparent  in  the  true  pelvis.  Although  this 
type  of  pelvic  dilatation  is  frequently  found  with  various 
forms  of  pelvic  infection,  it  may  be  regarded  as  typical  of 
pyelitis  occurring  with  stone  in  the  pelvis  or  calyces.  The 
increase  in  the  size  of  the  calyces  may  vary  in  extent  and 
character.  The  calyces  frequently  appear  to  be  increased  in 
number  as  a  result  of  the  dilatation  of  the  secondary  calyces. 


Fig.  112. — Inflammatory  dilatation. 

Marked  dilatation  of  the  upper  ureter,  particularly  at  the 
ureteropelvic  juncture,  is  commonly  seen  with  dilatation  in 
the  calyces.  In  Fig.  Ill  the  major  calyces  are  clubbed  and 
rounded  at  the  apices,  while  the  minor  calyces  are  effaced. 
There  is  no  apparent  increase  in  the  size  of  the  true  pelvis. 
The  ureter  is  dilated  throughout  as  the  result  of  infection 
arising  in  the  pelvis.  The  cause  of  this  infection  was  a  small 
stone  situated  in  the  pelvis.     In  Fig.  112  the  major  calyces 


INFLAMMATORY    DILATATION  149 

are  considerably  elongated  and  their  terminal  irregularities 
are  effaced.  The  dilatation  in  the  upper  ureter  is  a  dis- 
tinct aid  in  recognizing  the  existence  of  an  inflammatory 
process.  In  Fig.  113  the  major  calyces  are  elongated  and 
their  apices  are  clubbed  in  a  manner  suggestive  of  early  in- 
flammatory change.  The  constriction  usually  seen  in  the 
outline  of  the  ureteropelvic  juncture  is  absent.     Although 


Fig.  113. — Inflammatory  dilatation. 

the  ureter  is  dilated  in  its  entire  extent  as  the  result  of  in- 
fection, because  of  incomplete  distention  only  that  portion 
adjacent  to  the  pelvis  is  visible.  In  Fig.  114  the  major 
calyces  are  broadened  and  elongated.  The  upper  ureter, 
particularly  at  the  ureteropelvic  juncture,  is  dilated  almost 
to  the  width  of  the  true  pelvis.  In  Fig.  115  the  outline  of 
the  calyces  and  true  pelvis  is  approximately  normal,  and  with- 
out the  dilatation  evident  at  the  ureteropelvic  juncture,  it 


150 


PYELOGRAPHY 


Fig.  114. — Inflammatory  dilatation. 


Fig.  115. — Inflammatory  dilatation. 


INFLAMMATORY    DILATATION 


151 


would  be  impossible  to  determine  the  existence  of  a  previous 
infection  by  means  of  the  pyelogram.  In  Fig.  1 16  the  major 
calyces  are  clubbed  and  broadened,  particularly  at  their 
apices.  The  true  pelvis  does  not  appear  to  be  dilated. 
That  the  ureter  is  dilated  may  be  inferred  from  its  tortuous 
course,  even  though  it  is  only  partially  filled.  In  Fig.  95 
the  major  calyces  are  apparently  divisions  of  the  ureter. 


Fig.  116. — Inflammatory  dilatation. 

At  their  apices,  although  the  increase  in  size  is  largely  the 
result  of  low  ureteral  obstruction,  the  clubbed,  irregular 
outline  is  probably  the  result  of  secondary  infection.  The 
true  pelvis  and  ureter  are  evidently  not  dilated. 

Occasionally,  with  the  occurrence  of  a  small  stone  con- 
fined to  a  calyx,  the  dilatation  may  be  confined  to  that  calyx. 
In  Fig.  117  the  upper  major  calyx  in  the  right  pelvis  is  ir- 
regularly dilated  and  clubbed  and  the  minor  calyces  are 


152 


PYELOGRAPHY 


effaced.  The  other  major  calyces  and  the  true  pelvis  are 
seen  in  contrast  to  be  normal  in  outline.  The  dilatation 
was  the  direct  result  of  a  small  stone  lodged  in  the  calyx. 
It  is  possible,  however,  that  the  dilatation  may  be  par- 
tially the  result  of  mechanical  obstruction  as  well  as  sec- 
ondary infection  in  the  calyx. 

2.  Dilatation  Predominant  in  the  Pelvis. — The  true  pelvis 


Fig.  117. — Inflammatory  dilatation. 

may  be  dilated  to  a  varying  degree  without  any  marked 
changes  being  apparent  in  the  outline  of  the  calyces.  As 
a  rule,  the  dilatation  is  continuous  with  that  in  the  ureter. 
In  Fig.  1 18  dilatation  in  the  true  pelvis  is  visible.  The  gen- 
eral outline  of  the  calyces,  both  major  and  minor,  is  well 
retained.  More  complete  distention  would  probably  show 
greater  elongation  in  the  calyces.  In  Fig.  119,  although 
in  the  right  pelvis  the  major  calyces  appear  dilated    and 


Fig.  118. — Inflammatory  dilatation. 


Fig.  119. — Inflammatory  dilatation. 
153 


154  PYELOGRAPHY 

clubbed,  the  increase  in  size  of  the  true  pelvis  and  of  the 
ureter  at  the  ureteropelvic  juncture  is  predominant.  In 
Fig.  120  the  dilatation  in  the  true  pelvis,  which  is  con- 
tinued into  the  incompletely  filled  ureter,  is  more  prom- 
inent than  the  changes  visible  in  the  outline  of  the  calyces. 
3.  Dilatation  Involving  the  Entire  Pelvis. — When  the  in- 


Fig.  120. — Inflammatory  dilatation. 

flammation  becomes  well  advanced,  both  calyces  and  pelvis 
may  be  dilated  to  an  equal  degree.  Usually  the  dilatation 
in  the  ureter  also  will  be  well  marked.  In  Fig.  121  the 
major  calyces  are  enlarged  and  irregularly  clubbed  at  their 
apices,  while  the  minor  calyces  are  effaced.  Although  in- 
completely distended,  the  true  pelvis  is  apparently  well  di- 


INFLAMMATORY    DILATATION 


155 


lated.     The  extent  of  the  dilatation  in  the  upper  ureter  is 
not  apparent  because  of  incomplete  distention. 

4.  Dilatation  Predominant  in  the  Ureter. — When  the  di- 
latation is  predominant  in  the  ureter,  the  outline  of  the 
pelvis  is  either  but  slightly  dilated  or  is  contracted.  De- 
crease in  size  of  the  pelvic  outline  frequently  accompanies 
infection,  which  is  largely  confined  to  the  renal  parenchyma, 


Fig.  12 L — Inflammatory  dilatation. 

involving  the  pelvis  and  ureter  secondarily.  The  pelvis 
may  appear  markedly  contracted,  with  narrow  slits  repre- 
senting the  calyces.  The  outline  of  the  ureter,  if  well  dis- 
tended, will  appear  uniformly  dilated  as  the  result  of  in- 
fection. The  course  of  the  ureter,  particularly  in  its  upper 
portion,  is  frequently  tortuous  and  occasionally  appears 
markedly  angulated.  In  Fig.  122  the  marked  dilatation 
of  the  ureter  and  its  tortuous  course  would  indicate  the  ex- 


156  PYELOGRAPHY 

istence  of  an  inflammatory  process  even  more  than  the 
moderate  changes  visible  in  the  calyces.  In  Fig.  123  the 
left  pelvis  is  apparently  markedly  contracted  and  leads 
into  the  dilated  upper  ureter.     Although  the  degree  of  pelvic 


Fig.  122. — Inflammatory  dilatation. 

narrowing  may  be  exaggerated  by  the  difficulty  of  fully  dis- 
tending the  pelvis  because  of  the  dilated  condition  of  the 
ureter,  nevertheless  it  is  quite  evident  that  the  calyces  and 
pelvis  are  unusually  small.  In  Fig.  124  the  outline  of  the 
true  pelvis  and  calyces  appears   contracted.     The  marked 


INFLAMMATORY    DILATATION 


157 


Fig.  123. — Inflammatory  dilatation. 


Fig.  124. — Inflammatory  dilatation. 


158  PYELOGRAPHY 

angulation  visible  in  the  first  portion  of  the  right  ureter 
is  even  better  evidence  of  the  inflammatory  process  than 
the  slight  dilatation.  In  Fig.  125  the  upper  ureter  is  mod- 
erately dilated  and  is  acutely  angulated  at  the  ureteropelvic 
juncture.  The  calyces,  although  clubbed,  are,  together 
with  the  true  pelvis,  unusually  small.  In  Fig.  126  the  true 
pelvis  is  about  the  same  size  as  the  upper  ureter,  and  the 


Fig.  125. — Inflammatory  dilatation. 

major  calyces  are  represented  by  streaks.  The  ureter  shows 
considerable  inflammatory  dilatation,  although  incom- 
pletely distended.  In  Fig.  127  the  pelvis  is  incompletely 
filled  and  the  inflammatory  changes  are  suggested  in  the 
widely  separated  calyces.  The  ureter  is  not  only  markedly 
dilated,  but  is  twisted  back  on  itself  as  a  result  of  the  in- 
flammatory process.  In  Fig.  128  the  changes  in  the  pelvis 
are  not  marked.     The  injected  medium  returned  along  the 


Fig.  126. — Inflammatory  dilatation. 


Fig.  127. — Inflammatory  dilatation, 
159 


160 


PYELOGRAPHY 


catheter  but  a  short  distance,  giving  the  appearance  of  a 
locahzed  dilatation  in  the  ureter;  in  all  probability,  how- 
ever, the  ureter  is  dilated  in  its  entire  extent.  The  apparent 
obstruction  may  have  been  caused  either  by  kinking  of  the 
catheter  in  the  ureter  or  tortuosity  in  the  ureter  itself,  and 
by  the  fact  that  the  ureter  is  incompletely  filled. 

5.  Destruction  of  Pelvic  Outline  or  Pyonephrosis. — With 
extension    of   the   inflammatory    process    and    consequent 


Fig.  128. — Inflammatory  dilatation. 

destruction  of  the  normal  outline  of  the  calyces  the  cortex 
may  be  invaded  and  the  resulting  areas  of  necrosis  may 
merge  with  the  calyces.  The  areas  of  cortical  destruction 
which  extend  beyond  the  calyces  may  be  connected  by  nar- 
row isthmuses  with  the  apices,  so  as  to  give  a  very  irregular 
outline  to  the  pelvis.  As  the  inflammatory  process  disin- 
tegrates the  adjacent  tissue,  all  traces  of  normal  pelvic  out- 


INFLAMMATORY    DILATATION  101 

line  may  become  lost  and  the  pelvis  appear  as  a  large, 
irregular  sac  with  occasional  areas  scattered  through  the 
adjacent  parenchyma.  As  with  hydronephrosis,  the  re- 
tained fluid  often  dilutes  the  injected  medium  so  that  but 
one  or  two  dilated  calyces  may  appear  dimly  outlined.  It 
is  usually  unnecessary  to  make  a  pyelogram  with  advanced 
pyonephrosis,  since  the  clinical  and  cystoscopic  data  usually 


Fig.  129. — Inflammatory  dilatation. 

suffice  to  identify  the  condition.  However,  where  the  in- 
flammatory process  is  of  moderate  degree  and  when  the 
cystoscopic  data  are  doubtful,  the  pyelographic  evidence 
may  be  of  distinct  value.  In  Fig.  129  the  major  calyces 
are  irregularly  extended  and  are  clubbed  at  their  apices. 
In  areas  the  diffuse  outline  of  the  dilated  minor  calyces  is 
suggestive  of  cortical  necrosis.  In  Fig.  130  the  areas  of 
cortical  destruction  are  indicated  by  diffuse  shadows  ex- 
11 


162 


PYELOGRAPHY 


Fig.  130. — Inflammatory  dilatation. 


Fig.  131. — Inflammatory  dilatation. 


INFLAMMATORY    DILATATION  163 

tending  beyond  the  ends  of  the  calyces.  They  are  markedly 
irregular  and  the  borders  are  not  well  defined.  Other  calyces 
show  typical  inflammatory  changes.  In  Fig.  131  the  corti- 
cal destruction  is  considerable.  The  upper  cortical  areas 
of  necrosis  appear  detached,  the  connecting  isthmus  not  being 
visible.  The  lower  calyces  are  represented  by  diffuse  ir- 
regular areas.     The  outhne  of  the  pelvis  appears  indistinct, 


Fig.  132. — Inflammatory  dilatation. 

probably  because  of  incomplete  distention.  In  Fig.  132 
the  diffuse  shadow  in  the  upper  portion  of  the  pelvis  is  caused 
by  incomplete  distention  of  a  large  area  of  cortical  destruc- 
tion. The  outlines  of  the  lower  calyces  indicate  the  degree 
of  the  inflammatory  process.  In  Fig.  133  all  evidence  of 
the  original  pelvic  outline  is  lost.  Instead,  an  outline  of  a 
markedly  irregular  cavity  is  visible,  its  border  having  a  moth- 
eaten  outline.     A  few  scattered  areas  of  evident  cortical  ab- 


164  PYELOGRAPHY 

scesses   connected   with   the    pelvis    are  dimly  visible  and 
suggest  the  wide-spread  cortical  destruction. 

6.  Alternating  Contraction  and  Dilatation. — With  a  chronic 
inflammatory  process  largely  confined  to  the  renal  pelvis, 
its  outline  may  become  irregularly  contracted  as  well  as 
dilated.  This  may  be  due  either  to  contraction  as  the  re- 
sult of  inflammatory  changes  in  the  peripelvic  tissues  or 


Fig.  133. — Inflammatory  dilatation. 

to  encroachment  of  the  lumen  by  inflammatory  prolifera- 
tion of  the  pelvic  mucosa.  In  Fig.  134  the  outline  of  the 
renal  pelvis  and  upper  ureter  is  irregularly  narrowed  and 
dilated.  The  patient  complained  of  chronic  hematuria, 
which  at  operation  was  found  to  be  due  to  a  chronic  pye- 
litis granulosa.  The  changes  in  the  pelvis  itself  may  be 
due  to  the  encroaching  proliferation  of  the  mucosa,  while 
that  in  the  ureter  is  probably  due  to  changes  in  the  peri- 


INFLAMMATORY    DILATATION  165 

ureteric  and  peripelvic  tissue,  which  irregularly  retracted 
the  ureter  at  the  ureteropelvic  juncture  and  its  adjacent 
portion. 

7.  Atrophic  Contraction  of  Pelvis. — An  atrophic  condition 
of  one  or  both  kidneys  is  occasionally  observed.  Micro- 
scopic examination  of  the  renal  tissue  often  demonstrates 
the  existence  of  an  etiologic   inflammatory  process.     The 


Fig.  134. — Inflammatory  dilatation. 

resulting  cicatricial  changes  may  cause  diminution  in  the 
size  of  the  pelvis  commensurate  with  the  decrease  in  par- 
enchyma. The  various  clinical  data  usually  suffice  to  dis- 
close the  condition  when  bilateral.  A  careful  cystoscopic 
examination  with  functional  tests  when  necessary  usually 
determines  the  existence  of  unilateral  atrophy.  Occasion- 
ally, however,  the  pyelogram  may  offer  corroboratory  evi- 


166  PYELOGRAPHY 

dence  of  value.     The  pelvic  outline,  while  irregular,   ap- 
pears unusually  small. 

THE  URETER  (URETERITIS) 

As  with  inflammatory  changes  in  the  renal  pelvis,  an  in- 
flammatory process  in  the  ureter  is  followed  by  tissue  changes 
in  its  walls  which  cause  more  or  less  dilatation.  The  dila- 
tation resulting  from  inflammation  is  uniform  throughout 
the  course  of  the  ureter.  The  changes  in  the  pelvic  outline 
may  be  so  slight  as  to  remain  unrecognized,  whereas  the 
dilatation  in  the  ureter  may  be  the  only  evidence  of  a  pre- 
viously existing  inflammatory  process.  This  fact  is  occa- 
sionally taken  advantage  of  in  the  identification  of  small 
shadows  in  the  kidney  area. 

The  portion  of  the  ureter  situated  in  the  wall  of  the 
bladder  will  not  become  dilated  to  the  extent  of  the  ureter 
above  unless  the  bladder  itself  is  markedly  inflamed.  Di- 
latation of  this  portion  of  the  ureter  is  the  result  of  con- 
tiguous infection  and  is  usually  observed  only  with  marked 
chronic  cystitis  or  a  tuberculous  bladder  and  with  urinary  ob- 
struction. It  may  occasionally  be  demonstrated  by  filling 
the  bladder  with  an  opaque  solution  and  placing  the  patient 
in  the  Trendelenburg  position,  thus  permitting  the  fluid  to 
enter  the  ureter  by  gravity.  This  method  will  usually  be 
found  possible  when  the  ureter  in  the  wall  of  the  bladder  is 
dilated,  since  the  contraction  of  the  meatus  and  ureteric 
peristalsis  would  otherwise  prevent  the  fluid  from  entering 
the  ureter.  In  Fig.  135  the  lower  half  of  both  ureters  is  dis- 
tinctly dilated  as  far  as  the  wall  of  the  bladder.  The  physi- 
ologic area  of  narrowing  at  the  ureterovesical  juncture  is 
distinctly  shown.  The  vesical  portion  of  the  ureter  is  not 
dilated  to  the  degree  of  the  ureter  above.     In  Fig.  136  the 


INFLAMMATOIIY    DILATATION  1G7 


Fig.  135. — Inflammatory  dilatation  in  the  ureter. 


Fig.  136. — Inflammatory  dilatation  in  the  ureter. 


168  PYELOGRAPHY 

opaque  fluid  is  seen  outlining  the  bladder  with  the  patient 
in  the  Trendelenburg  position ;  the  fluid  has  gravitated  into 
the  left  ureter  to  a  short  distance,  and  demonstrates  the 
well-marked  inflammatory  dilatation. 

A  moderate  degree  of  inflammatory  dilatation  may  easily 
be  confused  with  a  considerable  degree  of  return  flow  in  an 
elastic  normal  ureter.     As  a  rule,  however,  the  outline  caused 


Fig.  137. — Normal  pelvis  with  return  flow. 

by  return  flow  is  irregularly  distributed  along  the  course  of 
the  ureter,  whereas  the  dilatation  caused  by  inflammation  is 
uniform.  With  return  flow  the  lower  portion  of  the  ureter 
is  seldom  outlined,  while  with  an  inflammatory  process  the 
dilatation  in  the  lower  portion  is  often  outlined  better  than 
in  the  upper.  In  Fig.  137  return  flow  from  the  pelvis  is 
visible  to  a  short  distance  below  the  ureteropelvic  juncture. 
That  no  inflammatory  process  is  present  may  be  inferred 


INFLAMMATORY    DILATATION  169 

from  the  noimal  outline  of  the  major  and  minor  calyces. 
In  Fig.  138  the  outline  of  the  well-filled  ureter  appears  so 
large  that  the  existence  of  a  moderate  degree  of  inflam- 
matory dilatation  must  be  inferred.  Moreover,  the  out- 
lines of  the  calyces  in  the  pelvis  are  slightly  clubbed,  hav- 
ing changes  which  occur  with  an  early  inflammatory  proc- 
ess.    The  lack  of  uniformity  in  the  ureteral  outline  is  the 


Fig.  138. — Inflammatory  dilatation  with  return  flow. 

result  of  incomplete  distention.  A  definite  degree  of 
inflammatory  change  in  the  ureter  is  very  evident  in  Fig. 
110.  The  dilatation  is  comparatively  uniform  throughout 
the  course  of  the  ureter.  The  first  portion  is  distinctly 
tortuous. 

With  a  marked  degree  of  inflammatory  change  in  the  wall 
of  the  ureter  the  course  of  the  ureter  may  become  quite  tor- 
tuous, particularly  in  the  first  third.     This  may  be  explained 


170  PYELOGRAPHY 

by  the  fact  that  the  ureteral  wall  as  it  becomes  dilated  in- 
creases in  a  longitudinal  as  well  as  a  lateral  direction.  Oc- 
casionally the  tortuous  course  may  aid  in  recognizing  the 
existence  of  a  mild  inflammatory  process  when  the  dilata- 
tion in  the  ureter  and  pelvis  is  so  slight  as  to  be  recognized 
with  difficulty.  In  Fig.  122  the  course  of  the  entire  ureter  is 
markedly  tortuous,  a  result  of  inflammation. 

With  extensive  dilatation  of  the  ureter  it  may  be  quite 
difficult  to  outline  satisfactorily  the  extent  of  the  inflam- 
matory process.  Because  of  the  dilatation,  the  injected 
fluid  may  rapidly  return  alongside  the  catheter  and  fail  to 
fill  the  ureter.  The  resulting  ureterogram  may  be  rather 
irregular  in  outline.  The  injected  fluid  usually  gravitates 
to  the  first  portion  of  the  ureter,  outlining  it  but  a  short  dis- 
tance. When  the  catheter  is  partially  withdrawn,  the  in- 
jected solution  may  outline  that  portion  adjacent  to  the 
bladder.  Unless  the  ureter  is  fairly  well  distended  by  the 
injected  medium,  a  moderate  degree  of  dilatation  may  be 
overlooked.  Marked  dilatation  of  the  ureter  is  frequently 
best  outlined  in  a  ureterogram  obtained  by  filling  the  ureters 
with  an  opaque  medium  through  gravity  after  the  patient's 
bladder  is  filled.  This  method  is  particularly  of  value  when, 
because  of  technical  difficulties,  it  is  impossible  to  find  either 
ureter.  In  Fig.  139  the  left  ureter  is  markedly  dilated  be- 
yond the  ureterovesical  juncture.  The  ureterogram  was 
obtained  by  means  of  the  gravity  method.  It  was  im- 
possible to  find  the  meatus  on  cystoscopy.  It  will  be  seen 
that  the  vesical  ureter  is  not  dilated  to  the  degree  of  the 
portion  above.  In  Fig.  120  the  ureter  is  greatly  dilated  and 
its  outline  is  visible  only  a  short  distance  beyond  that  of  the 
pelvis  because  of  insufficient  distention.  In  Fig.  140  the 
dilated  ureter  is  outlined  to  but  a  short  distance  above  the 


INFLAMMATORY    DILATATION 


171 


Fig.  139. — Inflammatory  dilatation  of  the  ureter. 


-fe'Jf&Sas.W 


Fig.  140. — Inflammatory  and  mechanical  dilatation  of  the  ureter. 


172 


PYELOGRAPHY 


bladder.  Although  at  operation  a  large  hydro-ureter  and 
hydronephrosis  were  found,  only  that  portion  of  the  lower 
ureter  visible  was  outlined  in  the  pyeloureterogram.  The 
difference  in  outline  between  a  well-distended  ureter  and  one 
partially  distended  is  well  illustrated  in  Figs.  141  and  142. 
The  dilatation  is  the  result  of  renal  infection  caused  by 
stone  in  the  upper  ureter.     In  Fig.  141  the  ureter  is  only 


/O  7/0 


Fig.  141. — Inflammatory  dilatation  in  the  ureter  (partially  distended). 

partially  distended  and  the  dilatation  not  apparent;  in 
Fig.  142  the  same  ureter  is  fully  distended  and  the  dilata- 
tion is  evidently  considerable. 


RENAL  TUBERCULOSIS 
The  peculiarities  in  the  pelvic  deformity  caused  by  renal 
tuberculosis   merit   special   description.     The   diagnosis   of 
renal  tuberculosis  can  usually  be  ascertained  by  means  of 


INFLAMMATORY    DI LATATION 


173 


demonstrating  the  presence  of  tubercle  bacilli  in  the  unne, 
clinical  data,  or  the  cystoscopic  examination.  However, 
guinea-pig  inoculation  may  be  impracticable,  and  micro- 
scopic examination  of  the  urine  may  be  negative,  while  the 
other  data  may  be  uncertain  and  so  occasionally  leave  the 


.#^fl.^ 


^z^^CC 


10710 


Fig.  142.— Inflammatory  dilatation  in  the  ureter  (more  completely  distended). 

diagnosis  of  renal  tuberculosis  in  doubt.  It  is  in  such  cases 
that  the  evidence  obtained  by  means  of  the  pyelogram  may 
be  the  only  method  by  which  to  obtain  the  correct  diagnosis. 
Only  when  the  diagnosis  is  in  doubt  should  pyelography  be 
employed.     The  chnical  and  cystoscopic  data  in  renal  tuber- 


174  PYELOGRAPHY 

culosis  and  pyelitis  may  be  similar  yet  insufficient  for  differ- 
ential diagnosis.  The  demonstration  in  the  pelvic  outline 
of  deformity  peculiar  to  renal  tuberculosis  will  then  be  of 
considerable  value. 

The  changes  in  the  pyelogram  found  to  accompany  tuber- 
culosis will  be  as  follows:  (1)  Dilatation  of  pelvis;  (2)  areas 
of  cortical  necrosis;    (3)  stricture  in  the  ureter. 

In  the  early  stages  of  renal  tuberculosis  evidence  of  the 
inflammatory  process  in  the  outline  of  the  pelvis  may  be  so 
slight  as  to  be  unrecognized.  When  pelvic  deformity  be- 
comes apparent,  it  may  closely  simulate  that  of  pyelo- 
nephritis, and  it  is  occasionally  impossible  to  differentiate 
between  the  two  conditions.  Pelvic  deformity  with  tuber- 
culosis predominates  in  the  outline  of  the  calyces.  The 
true  pelvis  is  usually  but  moderately  enlarged  unless  ure- 
teral stricture  should  cause  a  considerable  degree  of  me- 
chanical obstruction  or  pyonephrosis  be  present.  The  caly- 
ces appear  irregularly  dilated,  with  uneven  borders,  par- 
ticularly at  the  apices,  which  may  appear  as  if  detached 
from  the  pelvis.  Where  the  process  largely  involves  the 
pelvis  and  peripelvic  areas,  the  usual  regularity  of  the  pel- 
vic outline  is  lost  and  in  its  stead  will  be  found  a  dif- 
fuse, irregular  outline,  moth-eaten  in  appearance.  When 
the  process  is  confined  largely  to  the  cortex,  and  when 
areas  of  necrosis  are  minute,  the  pelvic  lumen  may  become 
contracted  in  a  manner  similar  to  certain  forms  of  pyelo- 
nephritis. In  Fig.  143  the  outhne  of  the  upper  major 
calyx  is  irregularly  dilated  and  the  minor  calyces  are  in- 
distinct. The  pelvis,  while  probably  incompletely  dis- 
tended, does  not  appear  normal.  The  outline  is  suggestive 
of  a  moderate  pyelonephritis.  At  operation  a  tuberculous 
focus  was  found  in  the  upper  pole.     In  Fig.  144  the  pre- 


INFLAMMATORY    DILATATION 


175 


Fig.  143. — Renal  tuberculosis. 


Fig.  144. — Renal  tuberculosis. 


176  PYELOGRAPHY 

dominant  dilatation  usually  seen  in  the  calyces  with  renal 
tuberculosis  is  apparent.  The  irregular  diffuse  borders 
of  the  upper  calyces  are  suggestive  of  early  necrosis,  and 
thus  differentiate  the  condition  from  ordinary  inflammatory 
dilatation.     In  Fig.  145  the  pelvis  is  apparently  contracted, 


Fig.  145. — Renal  tuberculosis. 

similar  to  that  seen  with  predominant  cortical  infection. 
The  ureter  is  tortuous  and  dilated  as  the  result  of  ureteritis 
as  well  as  of  probable  stricture  in  the  lower  ureter.  At 
operation  the  kidney  was  found  tuberculous. 

The  first  evidence  of  cortical  necrosis  will,  as  a  rule,  be 
visible  at  or  just  beyond  the  end  of  the  calyces.     The  caly- 


INFLAMMATORY    DILATATION  177 

ces  become  irregularly  enlarged  and  their  Ijorders  become 
indistinct.  As  the  inflammatory  process  extends,  the  ne- 
crotic areas  become  larger  and  may  cause  irregular  shadows 
adjacent  to  the  pelvic  outline  or  appear  as  irregular  areas 
scattered  in  various  parts  of  the  cortex.  Occasionally  the 
outline  of  the  necrotic  area  is  apparently  detached  from 


Fig.  146. — Renal  tuberculosis. 

the  pelvis  or  connected  with  it  by  a  narrow  isthmus.  Again 
the  areas  of  necrosis  are  seen  to  communicate  directly  with 
the  irregular  outline  of  the  pelvis.  As  the  inflammatory 
process  advances,  the  tissue  destruction  about  the  pelvis 
may  become  that  of  a  large  pyonephrosis.  The  areas  of 
cortical  necrosis  may  assume  irregular  forms  scattered 
through  the  parenchyma,  or  coalesce  to  form  a  large  ir- 

12 


178  PYELOGRAPHY 

regular  sac.  In  Fig.  146  the  small  areas  of  cortical  necrosis 
extending  beyond  the  ends  of  the  calyces  are  localized  and 
distinct.  In  Fig.  130  the  inflammatory  dilatation  is  con- 
fined largely  to  the  major  calyces.  Beyond  their  apices  ir- 
regular outlines  of  cortical  necrosis  are  visible.  In  Fig.  147 
the  necrosis  has  advanced  to  such  an  extent  that  large,  ir- 


Fig.  147. — Renal  tuberculosis. 

regular  areas  are  visible  extending  from  the  dimly  outlined 
left  pelvis.  In  Fig.  148  diffuse  cortical  necrosis  is  visible, 
extending  beyond  the  lateral  border  of  the  right  pelvis.  In 
contrast  is  the  normal  pelvis  on  the  other  side.  In  Fig.  149 
the  areas  of  cortical  necrosis  are  scattered  throughout  the 
lower  pole  of  the  kidney.     In  Fig.  150  the  condition  has 


INFLAMMATORY    DILATATION 


179 


Fig.  148. — Renal  tuberculosis. 


Fig.  149. — Renal  tuberculosis  (pyonephrosis). 


180  PYELOGRAPHY 

advanced  to  one  of  true  pyonephrosis,  with  large  abscess 
cavities  scattered  throughout  the  parenchyma. 

As  a  result  of  the  infectious  process  in  the  kidney  the 
ureter  will  usually  show  more  or  less  inflammatory  dilata- 
tion. Should,  however,  the  ureteral  mucosa  become  ul- 
cerated and  a  stricture  ensue,  the  resulting  mechanical  dila- 
tation may  be  considerable.     Occasionally  a  stricture  in  the 


Fig.  150. — Renal  tuberculosis  (pyonephrosis). 

ureter  appears  in  the  earlier  stages,  and  the  consequent  di- 
latation may  be  easily  confused  with  benign  stricture. 
More  often,  however,  where  the  tuberculous  process  is  ad- 
vanced to  such  a  degree  that  a  stricture  in  the  ureter  has 
formed,  there  will  be  more  or  less  evidence  of  inflammatory 
change  in  the  pelvic  outline  or  cortical  necrosis.  In  Fig. 
102  the  ureter  is  dilated  above  a  point  of  narrowing  in  its 
lower  portion.     The  clinical  and  cystoscopic  evidence  was 


INFLAMMATORY    DILATATION 


181 


Fig.  L51. — Renal  tuberculosis  (stricture  of  the  ureter). 


Fig.  152.— Renal  tuberculosis  (stricture  of  the  ureter). 


182  PYELOGRAPHY 

suggestive  of  a  simple  inflammatory  stricture  of  the  ureter. 
However,  the  marked  inflammatory  changes  in  the  outline 
of  the  pelvis  and  the  area  of  cortical  necrosis  connected 
with  the  upper  portion  of  the  pelvis  would  indicate  that  the 
process  is  tuberculous.  In  Fig.  151  the  ureter  is  markedly 
dilated  above  a  point  of  obstruction  6  or  7  cm.  above  the 
bladder.  The  pelvis  is  irregularly  dilated  and  the  shadows 
of  cortical  necrosis  are  seen  extending  in  various  directions. 
In  Fig.  152  the  ureter  is  markedly  dilated  as  the  result  of  a 
stricture  in  the  lower  ureter  as  well  as  of  inflammation.  The 
small  size  of  the  pelvis  may  be  explained  by  the  fact  that 
the  infection  is  scattered  throughout  the  parenchyma  and 
is  not  accompanied  by  any  great  degree  of  necrosis. 


CHAPTER  VII 

RENAL  STONE 

The  greatest  problems  in  the  interpretation  of  shadows  in 
the  kidney  area  are :  Their  identification  (whether  they  are 
intrarenal  or  extrarenal)  and  their  exact  localization  (if  in- 
trarenal,  in  what  portion  of  the  kidney).  The  pyelogram 
will  be  of  considerable  aid  in  the  solution  of  both  problems. 

SHADOW  IDENTIFICATION 
Most  of  the  shadows  in  the  kidney  area  may  be  identified 
by  their  contour,  character,  and  position;  frequently,  how- 
ever, the  shadow  of  the  renal  stone  assumes  an  atypical 
form — its  character  may  not  be  suggestive  of  stone,  and 
the  position  of  the  kidney  may  be  such  as  to  confuse  inter- 
pretation. Further,  extrarenal  conditions  may  occasion- 
ally be  the  cause  of  shadows  that  may  be  readily  confused 
with  renal  stone.  Not  infrequently  in  the  course  of  routine 
radiographic  examination  shadows  are  suggestive  of  renal 
stone  and  yet  the  clinical  data,  either  subjective  or  objective, 
would  negate  its  existence.  Data  other  than  those  derived 
from  the  ordinary  radiogram  will  frequently  be  necessary 
for  identification.  In  such  cases  the  data  obtained  by 
means  of  cystoscopic  inspection  and  the  ureteral  catheter 
are  often  sufficient  for  the  identification  of  the  stone;  in 
other  cases  shadows  can  be  identified  only  by  means  of 
pyelography.  The  method  should  not  be  employed  as  a 
routine  procedure,  however,  but  used  only  when  interpreta- 
tion is  doubtful  or  when  exact  localization  is  desirable. 

183 


184  PYELOGRAPHY 

The  pyelographic  data  which  will  enable  us  to  determine 
whether  a  doubtful  shadow  is  extrarenal  or  intrarenal  are 
as  follows:  (1)  The  distance  separating  the  shadow  from 
the  pelvic  outline;  (2)  the  exact  relation  of  the  shadow  to 
the  pelvic  outline;  (3)  the  presence  of  pathologic  changes 
in  the  pelvic  outline. 


Fig.  153. — Renal  stone  (identification). 

When  the  distance  separating  the  shadow  in  question 
from  the  pelvic  outline  is  three  or  four  inches,  the  extra- 
renal nature  of  the  shadow  will  be  demonstrated.  Should 
the  extrarenal  shadow  be  situated  adjacent  to  the  outline  of 
the  pelvis,  it  might  easily  be  confused  with  a  cortical  stone. 
In  Fig.  153  the  shadow  in  question  is  seen  to  lie  fully  three 
inches  below  the  level  of  the  normal  pelvis — a  distance  too 


RENAL    STONE 


185 


great  to  permit  of  its  being  within  the  renal  cortex.  At 
operation  the  shadow  was  found  to  be  caused  by  an  entero- 
lith lodged  in  a  retrocecal  appendix. 

A  careful  study  of  the  exact  relation  of  a  shadow  to  the 
outline  of  the  pelvis  usually  enables  one  to  differentiate  be- 
tween extra-  and  intrarenal  shadows.  It  will  be  found  that 
a  cortical  stone  is  usually  situated  at  or  near  the  end  of  a 


Fig.  154. — Shadow  in  the  left  renal  area. 


calyx,  rarely  at  its  side.  If  the  shadow  is  situated  lateral 
to  a  calyx,  or  if  it  overlaps  the  outline  of  the  calyx,  its  ex- 
trarenal nature  may  be  inferred.  A  small  shadow  situated 
so  as  to  be  obliterated  in  the  pyelogram  by  the  pelvic  out- 
line would  be  difficult  of  identification.  When  the  pelvic 
outline  is  normal,  it  may  be  easy  to  confuse  a  shadow  of  an 
intrapelvic  stone  with  that  of  an  extrarenal  object  lying  in 
direct  line  with  the  renal  pelvis.     A  stereoscopic  pyelogram 


186  PYELOGKAPHY 

might  be  of  some  aid  in  differentiation.  In  Fig,  154  a  small 
shadow  is  visible  in  the  left  kidney  area  at  a  short  distance 
below  the  twelfth  rib.  In  Fig.  155  the  shadow  is  situated 
lateral  to  and  some  distance  from  the  apex  of  the  upper 
major  calyx.  The  calyces  and  the  true  pelvis  are  normal 
in  outline.      The  relative  position  of  the  shadow  and  the 


Fig.  155. — Renal  stone  (pyelogram  of  Fig.  154). 

calyx,  as  well  as  the  absence  of  inflammatory  dilatation, 
would  determine  the  extrarenal  nature  of  the  shadow. 

A  variable  degree  of  dilatation  of  the  entire  pelvis  or  of 
the  individual  calyces  may  be  demonstrated  in  the  pyelo- 
gram in  the  majority  of  cases  when  a  stone  of  appreciable 
size  is  present  in  the  kidney.  The  change  in  the  pelvic  out- 
line will  be  the  result  either  of  mechanical  obstruction  or  of 
inflammatory  process,  or  of  both.     It  must  be  remembered, 


RENAL   STONE  187 

however,  that  a  stone  may  cause  little  or  no  apparent  de- 
formity. 

Inflammatory  Change. — Abnormality  in  the  outline  of 
the  renal  pelvis  as  the  result  of  inflammation,  as  has  been 
previously  described,  is  characterized  by  irregular  dilata- 
tion of  its  various  portions.  The  inflammatory  changes  in 
the  pelvic  outline  caused  by  stone  commonly  show  a  greater 
distention  of  the  individual  calyces  than  of  the  true  pelvis. 
When  the  stone  is  situated  in  the  pelvis  without  causing 
obstruction  to  urinary  drainage,  the  dilatation  is  usually 
confined  largely  to  the  individual  calyces.  Occasionally, 
however,  the  inflammatory  dilatation  will  predominate  in 
the  true  pelvis  with  comparatively  little  deformity  of  the 
calyces.  The  degree  of  deformity  in  the  pelvic  outline 
is  not  dependent  upon  the  size  of  the  stone.  It  not  infre- 
quently happens  that  a  comparatively  small  stone  will  cause 
considerable  deformity.  Again,  it  is  surprising  how  little 
deformity  sometimes  accompanies  a  stone  which  fills  prac- 
tically the  entire  pelvis. 

Although  with  small  stones  in  the  kidney  urinalysis  may 
show  practically  no  pathologic  elements,  the  pyelogram 
may  show  definite  changes  in  the  pelvic  outline,  the  result  of 
a  previously  existing  infection.  Slight  inflammatory  changes 
are  frequently  found  in  the  pelvis  of  a  kidney  in  which  small 
stones  have  repeatedly  formed  and  passed  at  irregular  inter- 
vals. Not  infrequently  the  inflammatory  dilatation  as  the 
result  of  infection  from  renal  stone  will  be  more  distinct  in 
the  ureter  than  in  the  pelvis.  Although  slight  inflamma- 
tory changes  in  the  pelvic  outline  as  the  result  of  stone  may 
disappear  after  the  removal  of  the  stone,  evidence  of  any  con- 
siderable dilatation  will  usually  be  permanent.  In  Fig.  156  a 
group  of  shadows  is  visible  in  the  right  kidney  area.     In  Fig. 


188 


PYELOGRAPHY 


Fig.  156. — Shadow  in  the  right  renal  area. 


Fig.  157. — Renal  stone  (pyelogram  of  Fig.  156). 


RENAL   STONE  189 

157  the  individual  calyces  are  dilated  so  as  to  form  an  irregu- 
lar triangular  outline  while  the  true  pelvis  is  unusually  small. 
The  stones  situated  in  the  calyces  and  pelvis  caused  pyelitis, 
which  in  turn  caused  the  inflammatory  dilatation.     In  Fig. 

158  a  stone  shadow  is  seen  in  the  right  kidney  area.  In 
Fig.  159  the  outUne  of  the  stone  is  obhterated  by  that  of 
the  true  pelvis,  which  is  well  dilated,  while  the  outlines  of 


Fig.  158. — Shadow  in  the  right  renal  area. 

the  calyces  appear  normal.      The  pelvic  dilatation  may  be 
caused  in  part  by  mechanical  obstruction. 

Mechanical  Dilatation. — It  would  be  logical  to  expect 
mechanical  distention  of  the  pelvis  to  result  from  the  ob- 
struction caused  by  a  stone  within  it.  This  occurs  to  a 
noticeable  degree  in  but  a  small  percentage  of  cases.  When 
present,  the  distention  is  characterized  by  an  increase  in  the 
outline  of  the  free  pelvis  proportionately  greater  than  that 


190  PYELOGRAPHY 

in  the  calyces.  Hydronephrosis  accompanying  stone  in  the 
pelvis  is  usually  smaller  than  that  found  accompanying 
constriction  in  the  upper  ureter  from  anatomic  conditions. 
Occasionally,  however,  a  stone  situated  at  the  uretero- 
pelvic  juncture  partially  obstructing  the  ureter  will  cause 
hydronephrosis  of  considerable  degree. 

Not  infrequently  the  pelvic  outline  assumes  the  character- 


Fig.  159. — Renal  stone  (pyelogram  of  Fig.  158). 

istics  of  both  mechanical  and  inflammatory  changes,  al- 
though the  latter  will  usually  predominate.  In  Fig.  160 
a  triangular  shadow  is  visible  in  the  right  kidney  area.  In 
Fig.  161  the  shadow  is  obscured  by  the  outline  of  the  di- 
lated pelvis.  The  relatively  large  outline  of  the  true  pelvis 
is  the  result  of  mechanical  obstruction.  The  irregularity  of 
the  calyces,  however,  is  the  result  of  marked  infection. 
Differential  Diagnosis. — Among  the  causes  for  confusion 


RENAL   STONE 


191 


Fig.  160. — Shadow  in  the  right  renal  area. 


Fig.  161. — Renal  stone  (pyelogram  of  Fig.  160). 


192  PYELOGRAPHY 

in  the  interpretation  of  shadows  in  the  radiogram  may  be 
mentioned  renal  tuberculosis.  As  a  rule,  the  various  types 
of  shadows  caused  by  the  calcium  in  necrotic  tuberculous 
renal  tissue  are  recognizable  in  the  radiogram.  Not  in- 
frequently, however,  such  areas  cause  shadows  which  may 
be  confused  with  actual  lithiasis.  Occasionally  stones  may 
actually  be  present  in  the  kidney  either  coincidental  or  sec- 
ondary to  the  tuberculous  process.  Shadows  caused  by  such 
calcareous  foci  can  usually  be  identified  by  means  of  cys- 
toscopic  examination  and  urinalysis,  although  it  may  at 
times  be  difficult  to  do  so.  The  demonstration  in  the  pyelo- 
gram  of  the  changes  in  the  pelvic  outline  usually  accom- 
panying tuberculosis  would  be  of  aid  in  identifying  the 
condition. 

Absence  of  Stone-shadow. — When  the  consistence  of  the 
stone  is  soft,  in  the  presence  of  large  amount  of  abdominal 
tissue  and  with  imperfect  radiographic  technic,  renal  stone 
may  not  be  detected  in  the  radiogram.  In  such  cases  the 
pyelogram  may  occasionally  demonstrate  the  changes  in 
the  pelvic  outline  which  usually  accompany  renal  stone,  and 
with  this  evidence  further  efforts  directed  toward  the  radio- 
graphic demonstration  of  the  stone  may  be  successful. 
Further,  it  has  been  found  that  solutions  of  colloidal  silver 
will  coat  the  surface  of  a  stone  to  such  a  degree  that  it  will 
cast  a  shadow.  If  a  radiogram  is  made  on  the  day  follow- 
ing a  pyelogram,  the  outline  of  a  stone  overlooked  in  a  pre- 
vious radiogram  may  be  rendered  visible  by  the  coating  of 
silver. 

SHADOW  LOCALIZATION 

It  is  of  value  to  the  surgeon  to  ascertain  the  exact  location 
of  the  stone  as  accurately  as  possible  prior  to  operation.  In 
bringing  the  kidney  into  the  field  of  operation  it  usually  be- 


RENAL    STONE  193 

comes  congested  and  enlarged  so  that  searching  it  for  a 
small  stone  may  be  exceedingly  difficult  and  often  fruitless. 
Localization  of  the  stone  shadow  in  the  original  radiogram  is 
frequently  possible  when  its  location  corresponds  with  the 
usual  position  of  the  renal  pelvis  and  when  the  outline  of  the 
kidney  is  distinct.  However,  should  the  stone  shadow  be 
situated  toward  either  pole  of  the  outline  of  the  kidney  or  at 
one  side  of  its  median  portion,  it  would  be  difficult  to  locate 
the  stone.  Moreover,  it  is  often  impossible  to  obtain  a  defi- 
nite outline  of  the  kidney  because  of  the  technical  difficulties 
involved.  Further,  the  outline  of  extrarenal  organs  occasion- 
ally simulates  that  of  the  kidney.  By  outlining  the  renal  pel- 
vis in  a  pyelogram  and  then  comparing  the  position  of  the 
stone  shadow  with  that  of  the  pelvic  outline,  the  stone  can  be 
localized  more  accurately  than  in  the  ordinary  radiogram. 
The  main  problem  in  the  localization  of  the  stone  is  to  de- 
termine whether  it  is  situated  in  the  true  pelvis,  in  a  calyx, 
or  in  the  cortex. 

Stone  in  the  True  Pelvis. — If  the  stone  is  situated  within 
the  pelvis,  its  shadow  will  either  be  obliterated  entirely  by 
that  of  the  injected  pelvis  or  it  will  be  seen  faintly  through 
it,  depending  upon  the  relative  density  of  the  stone  and  the 
injected  solution.  With  a  comparatively  weak  solution 
injected  into  the  pelvis,  and  with  the  injected  fluid  diluted 
by  retained  fluids,  the  stone  shadow  may  appear  fairly  dis- 
tinct through  the  pelvic  outline ;  therefore,  in  locating  stone 
shadows  it  would  be  advantageous  to  use  a  weak  solution 
of  the  injected  medium  provided  it  is  concentrated  enough 
to  show  pathologic  changes  in  the  pelvic  outline  for  the 
purpose  of  identification.  It  is  obvious  that  if  the  pelvis 
could  be  distinctly  outlined  by  means  of  a  gaseous  medium 
the  contrasting  shadows  of  gas  and  stone  would  permit  of 
13 


194 


PYELOGRAPHY 


Fig.  162. — Renal  stone. 


,  -jfji..'  5,....'.  . 


-  -.•  '.■» 


Fie.  163. — Shadow  in  the  right  renal  area. 


RENAL   STONE  195 

exact  localization.  In  Fig.  102  tho  shadow  of  a  large  round 
stone  is  seen  distinctly  tlirough  tho  faint  outhne  of  the 
partially  distended  pelvis.  The  fluid  retained  in  the  pelvis 
in  all  probability  diluted  the  injected  silver  solution  to  such 
an  extent  that  the  stone  shadow  remained  distinct.  In 
Fig.  163  a  small  shadow  suggestive  of  stone  is  apparent  in 
the  right  kidney  area.     In  Fig.  164  the  outline  of  the  stone 


Fig.  164. — Renal  stone  (pyelogram  of  Fig.  163). 

is  seen  faintly  through  the  pelvic  shadow  bulging  the  lower 
lateral  border.  Comparison  of  the  position  of  the  shadow 
in  the  original  plate  with  that  in  the  pyelogram  renders  the 
locaUzation  of  the  shadow  even  more  certain.  In  Fig.  165 
a  small  shadow  is  visible  in  the  right  kidney  area.  In  Fig. 
166  the  shadow  in  question  may  be  seen  accentuated  in  the 
center  of  the  true  pelvis.  The  calyces  show  considerable 
inflammatory  dilatation  and  clubbing,  while  the  true  pelvis 


196 


PYELOGRAPHY 


Fig.  165. — Shadow  in  the  right  renal  area. 


Fig.  166. — Renal  stone  (pyelogram  of  Fig.  165). 


RENAL   STONE  197 

is  not  increased  in  size.  In  Fig.  107  a  double  stone  shadow 
is  visible  in  the  left  kidney  area.  In  Fig.  168  the  shadow  is 
localized  at  the  ureteropelvic  juncture.  The  shadow  outline 
is  visible  through  that  of  the  pelvis,  which  is  slightly  dilated. 
In  Fig.  169  an  oval  shadow  is  visible  in  the  left  kidney  area. 
In  Fig.  170  the  outline  of  the  pelvis  almost  obliterates  that 
of  the  stone  shadow;   however,  the  outline  of  the  stone  may 


Fig.  167. — Shadow  in  the  left  renal  area. 

be  made  out  dimly  through  the  base  of  the  lowest  major 
calyx,  and  for  practical  purposes  may  be  considered  as 
lodged  in  the  true  pelvis.  Of  interest  is  the  apparent  ab- 
sence of  any  inflammatory  or  mechanical  dilatation  in  spite 
of  the  presence  of  so  large  a  stone.  In  Fig.  171  a  shadow  is 
apparent  in  the  left  kidney  area.  It  is  situated  in  the  lower 
portion  of  the  true  pelvis,  which  is  outlined  by  the  injec- 
tion of  oxygen.     The  pelvic  shadow  is  dark  in  contrast  to 


198 


PYELOGRAPHY 


Fig.  168. — Renal  stone  (pyelogram  of  Fig.  167). 


Fig.  169. — Shadow  in  the  left  renal  area. 


RENAL    STONE 


199 


Fig.  170. — Renal  stone  (pyelogram  of  Fig.  169). 


Fig.  171. — Renal  stone  (oxygen  pyelogram). 


200  PYELOGKAPHY 

the  white  stone  shadow.  The  pelvis  is  not  completely  dis- 
tended, and  the  finer  details  of  the  pelvic  outline  are  lost. 
In  Fig.  172  the  same  pelvis  is  outlined  by  means  of  col- 
loidal silver.  The  details  of  the  pelvic  outline  are  clear  and 
demonstrate  the  pathologic  changes  caused  by  the  stone. 

In  the  majority  of  pyelograms  the  shadow  of  stone  in  the 
true  pelvis  will  be  obliterated  by  the  pelvic  outline.     It  will 


Fig.  172. — Renal  stone  (colloidal  silver  pyelogram  of  Fig.  171). 

then  be  necessary  to  compare  the  situation  of  the  shadow 
in  the  original  plate  with  that  of  the  pelvis  in  the  pyelo- 
gram. It  is  obvious  that  it  would  be  of  advantage  to  main- 
tain the  same  angle  of  exposure  in  making  the  original  plate 
and  the  pyelogram;  otherwise  it  would  be  difficult  to  de- 
termine the  exact  location  of  the  shadow.  In  Fig.  173  a 
shadow  suggestive  of  a  calcareous  gland  or  gall-stone  is  situ- 
ated in  the  right  kidney  area.     In  Fig.  174  the  position  of 


Fig.  173. — Shadow  in  the  right  renal  area. 


Fig.  174. — Renal  stone  (pyelogram  of  Fig.  173) 
201 


202  PYELOGKAPHY 

the  shadow  in  question  corresponds  to  the  position  of  the 
renal  pelvis.  That  the  shadow  is  probably  intrapelvic  is  to 
be  inferred  from  the  dilatation  in  the  true  pelvis  and  calyces. 
In  Fig.  175  a  round  shadow  is  visible  in  the  right  kidney 
area.  In  Fig.  176  the  shadow  is  obliterated  by  that  of  the 
true  pelvis.  Of  interest  is  the  fact  that  the  outUne  of  the 
pelvis  does  not  appear  dilated,  notwithstanding  the  loca- 


Fig.  175. — Shadow  in  the  right  renal  area. 

tion  of  the  stone  in  the  true  pelvis.  In  all  probabihty  the 
pelvis  is  not  completely  filled.  However,  a  moderate  degree 
of  dilatation  is  visible  in  the  ureter,  demonstrating  the 
existence  of  an  infection  probably  caused  by  the  stone. 

Stone  in  the  Calyx. — Localization  of  a  shadow  to  a  certain 
calyx  is  possible:  (1)  When  the  stone  shadow  is  visible 
through  the  outline  of  the  calyx;  (2)  when  the  peculiarities 
in  the  outline  of  the  calyx  correspond  with  those  seen  in  the 


RENAL   STONE  203 

stone  shadow,  and  (3j  when  the  position  of  the  cal^'x  C(jr- 
responds  with  that  of  the  stone  in  the  original  plate. 

Occasionally,  however,  a  stone  may  be  lodged  in  a  calyx 
without  any  data  being  present  to  define  its  exact  localiza- 
tion. All  the  calyces  may  be  dilated  to  about  the  same 
extent  and  character  and  offer  no  localizing  peculiarities. 
Further,  the  relative  position  in  the  two  plates  may  be  in- 


Fig.  176. — Renal  stone  (pyelogram  of  Fig.  175). 

exact,  so  that  on  comparing  the  position  of  the  original 
shadow  in  the  radiogram  with  that  in  the  pyelogram  we  may 
find  it  very  difficult  to  decide  in  which  calyx  the  stone  is 
located.  With  equal  dilatation  of  all  calyces,  the  stone  is 
usually  in  the  true  pelvis;  when  one  calyx  is  considerably 
larger  than  the  others,  it  is  apt  to  contain  the  stone.  A 
stone  in  the  calyx  will  cause  dilatation  of  the  calyx  either  as 


204  PYELOGRAPHY 

a  result  of  secondary  infection  or  mechanical  obstruction. 
As  a  rule,  the  inflammatory  changes  are  more  prominent 
than  the  mechanical,  although  evidence  of  both  may  be  ap- 
parent. A  stone  situated  in  a  calyx  the  base  of  which  is 
broad  and  open  to  the  lumen  of  the  true  pelvis  should  be 
considered  as  a  pelvic  stone.  When  the  isthmus  is  so  nar- 
row that  a  stone  in  the  calyx  could  not  be  removed  through 


Fig.  177. — Shadow  in  the  right  renal  area. 

the  pelvis,  the  stone  should  not  be  described  as  in  the  pelvis. 
It  may  sometimes  be  difficult  to  determine  whether  a  stone 
which  apparently  lies  in  the  calyx  can  be  removed  through 
the  pelvis  or  whether  nephrotomy  is  necessary. 

The  same  principles  governing  the  visibility  of  stone  in 
the  injected  pelvis  will  determine  whether  the  stone  can  be 
seen  in  the  outhne  of  the  calyx.     In  Fig.  177  a  double  stone 


RENAL   STONE 


205 


Fig.  178. — Renal  stone  (pyelogram  of  Fig.  177). 


Fig.  179. — Shadow  in  the  right  renal  area. 


206  PYELOGRAPHY 

shadow  is  visible  in  the  right  kidney  area.  In  Fig.  178  the 
outline  of  one  end  of  the  stone  is  visible  in  the  upper  calyx, 
which  is  evidently  dilated.  Judging  from  the  width  of  the 
base  of  the  calyx,  the  stone  could  be  removed  through  the 
pelvis.  In  Fig.  179  a  stone  shadow  is  visible  in  the  right 
kidney  area.  In  Fig.  180  the  outline  of  the  lowest  calyx 
corresponds  in  shape  with  that  of  the  stone.     On  comparing 


Fig.  180. — Renal  stone  (pyelogram  of  Fig.  179). 

the  relative  position  of  the  stone  shadow  in  Fig.  179  and  the 
last  rib  with  that  of  the  lowest  calyx  in  Fig.  180,  the  two  are 
seen  to  be  identical.  In  Fig.  181  a  round  shadow  is  visible 
in  the  right  kidney  area.  In  Fig.  117  the  upper  calyx  is 
dilated  and  considerably  larger  than  the  other  calyces,  which 
are  normal  in  outline.  From  the  localized  dilatation  and 
the  corresponding  position  it  is  evident  that  the  stone  is 
located  in  the  upper  calyx. 


RENAL    STONE 


207 


Not  infrequently  a  stone  will  be  found  situated  at  the 
end  of  a  calyx,  so  that  it  lies  partly  in  the  end  of  the  calyx 
and  partly  in  the  cortical  tissue.  It  may  be  impossible  to 
differentiate  between  a  stone  at  the  end  of  the  calyx  and  one 
which  is  definitely  in  the  cortex.  In  Fig.  182  the  stone 
shadow  lies  adjacent  to  the  end  of  the  lowest  calyx.  Neither 
inflammatory  nor  mechanical  changes  are  visible  in   the 


Fig.  181. — Renal  stone  (see  Fig.  117  for  pyelogram). 

pelvic  outline.  The  stone  shadow  should  properly  be  con- 
sidered as  being  cortical,  since  nephrotomy  is  necessary  for 
its  removal. 

Cortical  Stone. — A  shadow  appearing  a  short  distance 
beyond  the  end  of  a  calyx,  accompanied  by  inflammatory 
changes  in  the  pelvic  outline,  would  necessarily  be  caused 
by  a  stone  in  the  cortex.  The  majority  of  cortical  stones 
will  cause  more  or  less  inflammatory  dilatation  of  the  calyces 


208  PYELOGEAPHY 

or  pelvis  as  a  result  of  previous  or  present  infection. 
Occasionally,  however,  the  cortical  stone  may  cause  little 
or  no  inflammatory  reaction  and  the  pelvic  outline  is  normal. 
If  such  a  stone  shadow  is  4  or  5  cm.  distant  from  the  calyx, 
it  may  easily  be  confused  with  an  extrarenal  shadow.  The 
greatest  problem,  therefore,  in  the  identification  of  a  cortical 
stone  is  its   differentiation   from  extrarenal   shadows.     In 


Fig.  182.— Renal  stone. 

Fig.  183  a  small  shadow  is  visible  in  the  left  kidney  area. 
In  Fig.  184  the  same  shadow  is  apparent  beyond  the  apex  of 
the  caudal  calyx  and  is  distinctly  cortical.  The  outline  of 
the  pelvis  shows  general  inflammatory  irregularity  as  the 
result  of  infection  caused  by  the  stone.  In  Fig.  185  a  stone 
shadow  is  situated  at  the  apex  of  the  lower  calyx  and 
partially  protruding  into  it.  The  inflammatory  change  in 
the  incompletely  distended  pelvis  and  ureter  is  evident. 


RENAL    STONE 


209 


Fig.  183. — Shadow  in  renal  area. 


Fig.  184. — Renal  stone  (pyelogram  of  Fig.  183). 


14 


210  PYELOGRAPHY 

Multiple  Shadows. — Multiple  shadows  often  appear  in 
the  radiogram,  one  or  more  of  which  require  identification 
and  localization.  The  shadows  of  multiple  stones  in  the 
kidney  do  not  necessarily  have  similar  characteristics,  so 
that,  while  the  shadow  of  one  stone  may  be  typical,  that  of 


Fig.  185. — Renal  stone. 

the  other  may  be  suggestive  of  extrarenal  conditions.  The 
distance  separating  the  two  shadows  in  the  kidney  area  may 
be  so  great  as  to  suggest  that  one  may  be  intrarenal,  and 
that  the  other  is  extrarenal. 

The  pyelogram  is  of  value  not  alone  in  the  identification 


RENAL   STONE 


211 


Fig.  186. — Shadows  in  renal  area. 


Fig.  187. — Renal  stone  (pyelogram  of  Fig.  186). 


212  PYELOGRAPHY 

of  the  various  shadows,  but  also  in  their  locahzation.  One  of 
several  stones  may  be  situated  within  the  true  pelvis  or  at 
the  ureteropelvic  juncture,  and  the  others  in  the  calyces 
or  in  the  cortex.  In  Fig.  186  two  shadows,  the  lower  of 
which  is  atypical  of  renal  stone,  are  visible  in  the  right  kid- 
ney area.  In  Fig.  187  the  outline  of  the  upper  shadow 
may  be  seen  through  that  of  the  true  pelvis,  while  the  lower 


Fig.  188. — Shadows  in  renal  area. 

shadow  is  distinctly  visible  in  the  ureter  below  the  uretero- 
pelvic juncture.  The  inflammatory  changes  in  the  outline 
of  the  pelvis  corroborate  the  intrarenal  nature  of  the 
shadows.  In  Fig.  188  a  large  and  a  small  shadow  are  situ- 
ated in  the  right  kidnej^  area.  In  Fig.  189  the  larger  of  the 
two  shadows  is  evidently  situated  at  the  ureteropelvic  junc- 
ture. By  comparing  the  situation  of  the  shadows  it  is 
apparent  that  the  smaller  shadow  is  pocketed  in  the  lowest 


RENAL    STONE 


213 


Fig.  189. — Renal  stone  (pyelogram  of  Fig.  188). 


Fig.  190. — Shadows  in  renal  area. 


214  PYELOGRAPHY 

calyx.  The  operative  indications,  therefore,  would  be  pye- 
lotomy  for  the  larger  stone  and  nephrotomy  for  the  smaller 
one. 

Not  infrequently  a  considerable  distance  separates  the 
two  shadows,  and  yet  both  of  them  may  be  found  in  the 
pelvis.  In  Fig.  190  two  small  shadows  situated  in  the  left 
kidney  area  are  separated  by  a  distance  of  several  centi- 


Fig.  191. — Renal  stone  (pj'elogram  of  Fig.  190). 

meters.  In  Fig.  191  both  shadows  are  obliterated  and  are 
evidently  lying  in  the  true  pelvis  or  in  the  open  calyces,  and 
probably  both  could  be  removed  by  pyelotomy. 

Estimation  of  Renal  Function. — A  very  difficult  feature 
in  the  diagnosis  of  renal  lithiasis  is  the  clinical  estimate  of 
the  degree  of  functional  capacity  remaining  in  the  affected 
kidney.  The  amount  of  pus  in  the  urine  catheterized  from 
the  affected  kidney  does  not  always  indicate  the  degree  of 


RENAL   STONE 


215 


functional  destruction,  nor  does  temporary  cessation  of 
secretion,  as  observed  through  cystoscopic  inspection,  in- 
dicate diminution  in  the  amount  of  secretory  substance. 
Estimation  of  renal  functional  capacity  by  means  of  chemical 
tests  has  frequently  been  found  inaccurate  in  case  of  renal 
lithiasis.  By  demonstrating  the  extent  and  character  of  the 
pathologic  changes  in  the  renal  pelvis  by  means  of  the  pyelo- 


Fig.  192. — Pyonephrosis  with  renal  stone. 

gram  one  can  frequently  determine  with  a  comparative  degree 
of  accuracy  the  amount  of  secretory  tissue  remaining.  When 
the  pelvis  appears  irregular  and  markedly  dilated,  and  when 
the  calyces  extend  irregularly  to  a  considerable  distance,  the 
parenchyma  will  usually  be  found  involved  in  the  inflamma- 
tory process  to  such  an  extent  that  nephrectomy  will  be 
necessary.  On  the  other  hand,  occasionally  the  pelvic  outline 
will  show  but   moderate  changes   and  still   the  functional 


216  PYELOGRAPHY 

capacity  of  the  kidney  may  be  markedly  diminished  as  the 
result  of  the  chronic  pyelonephritis.  In  Fig.  192  the  irregular 
areas  outline  pyonephrotic  calyces  caused  by  multiple  cortical 
stones.  It  is  apparent  that  the  degree  of  cortical  destruction 
will  necessitate  nephrectomy.  In  Fig.  193  a  similar  con- 
dition is  apparent. 


Fig.  19.3. — Pyonephrosis  with  renal  stone. 
GALL-STONES 

It  is  well  known  that  a  gall-stone  is,  as  a  rule,  not  visible 
in  the  radiogram.  Nevertheless,  as  a  result  of  the  improve- 
ment in  radiographic  technic  it  is  being  found  with  such 
frequency  as  to  warrant  its  consideration  in  the  interpre- 
tation of  every  shadow  in  the  upper  right  abdomen.  The 
similarity  of  subjective  symptomatology  which  not  infre- 
quently occurs  between  renal  stone  and  gall-stone  may 
render  the  clinical  data  of  little  aid  in  interpreting  such 


RENAL    STONE  217 

shadows.  While  the  character  of  the  gall-stone  shadow  is 
distinctive  and  frequently  is  easily  recognized,  yet  error 
in  interpretation  is  easily  possible.  The  greatest  problem 
in  the  x-ray  diagnosis  of  gall-stone  is  the  differentiation 
of  its  shadow  from  that  of  renal  stone.  The  radiographic 
shadow  caused  by  the  majority  of  gall-stones  is  character- 
ized by  accentuation  of  the  cortex  and  by  an  indistinct  cen- 


Fig.  194.— Gall-stone. 

ter.  They  usually  appear  more  or  less  circular  in  outline, 
and  not  infrequently  appear  in  groups.  However,  the  gall- 
stone shadow  may  assume  a  great  variety  of  shapes  and 
characters  and  may  frequently  simulate  closely  the  char- 
acteristics of  the  renal  stone  shadow.  It  may  lie  in  the 
region  of  the  kidney,  and,  should  there  be  a  coincidental  in- 
fection of  the  urinary  tract,  the  diagnosis  might  be  exceed- 
ingly difficult.     On  the  other  hand,  renal  stone  may  not 


218  PYELOGRAPHY 

infrequently  be  seen  lying  well  above  the  twelfth  or  even 
the  eleventh  rib,  in  the  usual  gall-bladder  area.  Further, 
the  renal  stone  shadow  may  assume  characteristics  very 
similar  to  those  of  the  gall-stone.  In  short,  the  shadow 
cast  in  the  radiogram  by  the  gall-stone  and  by  the  renal  stone 
may  be  identical  in  position  and  character.  The  pyelogram 
is  usually  the  best  and  frequently  the  only  method  by  which 


Fig.  195. — Multiple  gall-stones. 

the  gall-stone  may  be  identified.  The  same  data  previously 
described  in  the  identification  of  the  extrarenal  shadow  are 
applicable  in  the  differentiation  between  gall-stones  and 
renal  stones.  In  Fig.  194  the  shadow  in  question,  although 
situated  in  the  usual  kidney  area,  is  widely  separated  from 
the  outline  of  the  pelvis  below.  The  distance  between 
them  is  too  great  to  permit  the  stone  shadow  to  be  in  the 
upper  pole.     Further,   the  outline  of  the  low-lying  pelvis 


RENAL    STONE 


219 


Fia;.  196. — Shadow  in  renal  area. 


Fig.  197. — Gall-stone  (pyelogram  of  Fig.  196). 


220  PYELOGRAPHY 

shows  no  evidence  of  inflammatory  dilatation  which  would 
be  expected  with  a  renal  stone  of  that  size.  In  Fig.  195 
a  group  of  shadows  is  visible  at  a  considerable  distance  be- 
low the  normal  pelvic  outline.     A  tumor  palpated  on  clin- 


Fiff.  198. — Shadows  in  renal  area. 


ical  examination  was  identified  by  means  of  the  pyelogram 
as  a  distended  gall-bladder  containing  numerous  gall-stones. 
In  Fig.  196  a  shadow  suggestive  of  gall-stone  is  situated  in 
a  possible  kidney  position.  In  Fig.  197  the  shadow  is  seen 
close  to  the  apex  of  the  upper  calyx,  and  it  might  be  in- 


RENAL   STONE 


221 


Fig.  199. — Shadow  identification  (gall-stone)  (pyelogram  of  Fig.  19S). 


Fig.  200. — Shadow  in  renal  area. 


222 


PYELOGKAPHY 


Fig.  201. — Shadow  identification  (gall-stone)  (pyelogram  of  Fig.  200). 


Fig.  202. — Shadow  in  renal  area. 


RENAL   STONE  223 

f erred  that  it  lies  in  the  upper  pole;  however,  the  normal 
outline  of  the  calyces,  true  pelvis,  and  ureter  would  exclude 
such  a  possibility.  In  Fig,  198  two  irregular  shadows  are 
apparent  in  the  right  kidney  area.  In  Fig.  199  the  shadows 
are  adjacent  to  that  of  the  renal  pelvis,  in  a  situation  similar 
to  that  of  cortical  renal  stone.     However,  the  absence  of 


Fig.  203. — Shadow  identification  (gall-stone)  (pj^elogram  of  Fig.  202). 

any  inflammatory  changes  in  the  pelvis  or  ureter  would 
hardly  be  possible  with  renal  stones  of  such  size  and  form. 
At  operation,  multiple  gall-stones  were  removed.  In  Fig. 
200  a  shadow  suggestive  of  gall-stone  from  its  character  is 
so  situated  in  relation  to  the  opaque  catheter  as  to  locate  it 
in  the  lower  pole  of  the  kidney.  In  Fig.  201  the  distance 
separating  the  shadow  from  the  pelvic  outline  would  de- 


224 


PYELOGRAPHY 


Fig.  204. — Shadow  in  renal  area. 


Fig.  205. — Shadow  identification  (gall-stones)  (pyelogram  of  Fig.  204). 


RENAL   STONE 


225 


Fig.  206. — Shadow  in  renal  area. 


Fig.  207. — Renal  stone  (pyelogram  of  Fig.  206). 


15 


226  PYELOGRAPHY 

termine  its  extrarenal  nature.  Further,  the  outhnes  of  the 
calyces  are  normal.  In  Fig.  202  a  shadow  with  a  well- 
marked  cortical  rim  suggestive  of  gall-stone  is  seen  in  the 
kidney  area.  In  Fig.  203  the  shadow  is  adjacent  to  the 
outline  of  the  true  pelvis  and  lateral  to  the  isthmus  of  the 
upper  calyx.  Since  a  renal  cortical  stone  is  rarely  found 
at  the  side  of  the  calyx,  this  alone  would  determine  the 
extrarenal  nature  of  the  shadow.  The  normal  outline  of 
the  pelvis  would  also  identify  the  shadow.  In  Fig.  204  a 
large  shadow  is  visible  in  the  right  kidney  area.  In  Fig. 
205  the  shadow  evidently  overlaps  the  outline  of  a  normal 
pelvis,  which  would  be  impossible,  and  it  may  be  inferred 
that  the  stone  is  extrarenal.  In  Fig.  206  a  shadow  is  visible 
in  the  right  kidney  area  which  is  suggestive  of  gall-stone  in 
character.  In  Fig.  207  the  shadow  is  obliterated  by  that 
of  the  renal  pelvis,  which  is  dilated  as  the  result  of  infec- 
tion caused  by  stone.  This  shadow  is  manifestly  caused  by 
a  stone  in  the  renal  pelvis. 


CHAPTER  VIII 
URETERAL  STONE 

The  numerous  conditions  other  than  stone  which  may  be 
the  cause  of  shadows  in  a  radiogram  of  the  ureteral  area  will 
frequently  make  their  interpretation  a  difficult  problem. 
Data,  other  than  those  derived  from  subjective  symptoms 
and  the  usual  physical  examination,  are  often  necessary  for 
the  identification  of  such  shadows.  As  with  renal  stone, 
cystoscopic  inspection  and  the  ureteral  catheter  will  fre- 
quently suffice  for  their  identification.  Often,  however, 
the  pyelo-ureterogram  offers  data  of  greater  accuracy. 

The  changes  in  the  outline  of  the  ureter  caused  by  ureteral 
stone  may  be  the  result  of  either  mechanical  obstruction  or 
of  a  complicating  inflammatory  process  or  of  both  factors. 
These  changes  may  be  rendered  visible  in  the  ureterogram, 
and  will  usually  determine  whether  the  shadow  in  question 
is  extra-  or  intra-ureteral.  The  data  to  be  obtained  by 
means  of  the  ureterogram  in  the  diagnosis  of  ureteral  stone 
are  as  follows:  (1)  Nodular  dilatation  of  the  ureter  at  the 
site  of  the  stone;  (2)  dilatation  above  the  shadow  in  the 
ureter  or  pelvis ;  (3)  dilatation  of  the  ureter  below  the  stone 
as  a  result  of  ureteritis;  (4)  absence  of  fluid  shadow  above 
the  stone  shadow  while  present  immediately  below  it. 
When  none  of  these  data  are  apparent  in  the  ureterogram, 
the  shadow  in  question  may  be  regarded  as  extra-ureteral. 

Nodular  Dilatation. — Dilatation  of  the  ureter  as  the  re- 
sult of  stone  may  be  confined  to  that  portion  immediately 
surrounding  the  stone  shadow.     Consequently,  a  nodular 

227 


228  PYELOGRAPHY 

dilatation  at  the  site  of  a  doubtful  shadow  would  suffice  to 
identify  its  intra-ureteral  nature.  Occasionally  the  ureteral 
dilatation  is  apparently  localized  because  of  insufficient 
distention.  The  nodular  dilatation  may  be  very  slight 
in  the  presence  of  a  small  stone.  The  amount  of  col- 
loidal silver  injected  may  be  insufficient  to  outline  the 
ureter,  and,  although  there  may  then  be  but  little  nodular 


Fig.  208. — Ureteral  shadow. 

dilatation  visible  at  the  site  of  the  stone,  enough  of  the 
solution  will  usually  be  injected  to  envelop  the  shadow 
partially  and  so  demonstrate  its  intra-ureteral  nature.  In 
Fig.  208  a  small  shadow  is  visible  in  the  region  of  the  left 
lower  ureter.  In  Fig.  209  the  ureter  is  seen  to  be  dilated 
to  a  moderate  degree  only  at  the  site  of  the  stone.  In  Fig. 
210  a  shadow  is  visible  in  the  area  of  the  right  lower  ureter. 
In  Fig.  211  the  shadow  is  obliterated  by  the  outline  of  the 


URETERAL   STONE 


229 


V: 


0>' 


.^ 


Fig.  209. — Ureteral  stone  (ureterogram  of  Fig.  208j. 


Fig.  210. — Ureteral  shadow. 


230 


PYELOGRAPHY 


Fig.  211. — Ureteral  stone  (ureterogram  of  Fig.  210). 


Fig.  212. — ^Ureteral  shadow. 


URETERAL   STONE  231 

ureter  which  is  apparently  dilated  in  the  immediate  vicinity 
of  the  stone.  In  all  probability  the  ureter,  if  fully  distended, 
would  appear  larger  throughout  its  course.  In  Fig.  212 
a  shadow  is  visible  in  the  area  of  the  left  lower  ureter.  In 
Fig.  213  a  nodular  dilatation  is  apparent  in  the  outline  of 
the  lower  ureter  which  corresponds  to  the  position  of  the 
stone  shadow  in  Fig.  212.     The  shadow  may  therefore  be 


Fig.  213. — Ureteral  stone  (ureterogram  of  Fig.  212). 

regarded  as  intra-ureteral.  In  Fig.  214  a  stone  shadow  is 
situated  in  the  region  of  the  lower  portion  of  the  right 
ureter.  In  Fig.  215  the  opaque  catheter  is  in  close  apposi- 
tion to  the  shadow.  The  injected  solution  has  returned 
alongside  the  catheter  so  that  it  has  partially  enveloped  the 
stone  shadow,  showing  that  the  shadow  in  question  is 
within  the  ureter. 

If  a  marked  localized  sacculation  of  the  ureter  or  a  divertic- 


232 


PYELOGRAPHY 


Fig.  214. — Ureteral  shadow. 


Fig.  215. — Ureteral  stone  (ureterogram  of  Fig.  214). 


URETERAL   STONE  233 

ulum  is  present  at  the  site  of  the  stone,  the  exact  condition 
would  be  demonstrated  in  the  ureterogram.  If  the  rela- 
tion of  a  stone  so  situated  to  an  opaque  catheter  were  re- 
lied upon,  the  distance  separating  the  two  would  easily  lead 
one  to  believe  the  stone  to  be  extra-ureteral.     Such  local- 


Fig.  216. — Ureteral  stone  and  dilatation. 

ized  dilatation  at  the  site  of  the  stone  may  be  indicative  of 
marked  periureteritis  or  even  of  perforation  of  the  ureter 
caused  by  the  stone. 

Dilatation  Above  Ureteral  Shadow.— The  extent  of  the 
dilatation  which  may  be  apparent  above  a  stone  in  the 
ureter  will  vary  with  the  degree  of  obstruction.     The  dila- 


234 


PYELOGRAPHY 


tation  may  be  so  slight  that  it  is  difficult  of  differentiation 
from  the  shadow  caused  by  return  flow  of  the  injected  fluid 
which  is  frequently  seen  in  a  flaccid  ureter.  Further,  a 
ureter  may  be  dilated  to  a  considerable  extent,  but  unless  it 
is  fully  distended,  the  dilatation  may  not  be  rendered  vis- 
ible in  the  ureterogram.  As  a  rule,  however,  a  moderate 
degree  of  dilatation  will  be  readily  demonstrated  in  the 


Fig.  217. — Ureteral  shadow. 

ureterogram.  Marked  ureteral  dilatation  may  be  difficult 
to  outline  completely  because  the  injected  fluid  is  diluted 
by  the  fluid  retained  in  the  ureter.  In  Fig.  216  the  stone 
shadow  is  visible  at  a  short  distance  below  the  dilated  ureter. 
The  ureter  is  well  dilated  above  the  ureterovesical  juncture 
as  the  result  of  stone  obstruction.  In  Fig.  217  a  small 
shadow  is  visible  in  the  region  of  the  right  lower  ureter.  In 
Fig.  218  a  slight  degree  of  dilatation  is  apparent  extending 


URETERAL    STONE 


235 


Fig.  2 18. ^Ureteral  stone  (ureterogram  of  Fig.  218). 


Fig.  219. — Ureteral  stone  (pyeloureterogram  of  Fig.  218). 


236  PYELOGRAPHY 

above  the  shadow.  In  Fig.  219  the  upper  ureter  is  sHghtly 
tortuous  and  the  pelvic  outline  shows  minor  dilatation  in 
the  calyces.  In  Fig.  220  a  shadow  is  visible  in  the  left  kid- 
ney area.  In  Fig.  221  the  same  shadow  has  shifted  its 
position  to  the  region  of  the  upper  ureter.  That  the  ureter 
is  markedly  dilated  may  be  inferred  from  the  absence  of  any 


Fig.  220. — Shadow  in  the  renal  area. 

trace  of  the  diluted  solution  injected  into  the  ureter.  A 
marked  degree  of  hydronephrosis  is  apparent  resulting  from 
evident  mechanical  obstruction  caused  by  the  stone.  In 
Fig.  222  a  small  shadow  is  visible  in  the  area  of  the  right 
lower  ureter.  In  Fig.  223  the  stone  shadow  is  apparently 
continuous  with  the  outline  of  the  partially  distended  ureter. 
This  is  caused  by  the  injected  fluid  partially  enveloping  the 


URETERAL   STONE 


23- 


stone.  In  Fig,  224  the  ureter  is  more  fully  distended  and 
the  relation  of  the  stone  to  the  dilated  ureter  is  more 
apparent. 

Difference  in  degree  of  ureteral  dilatation  occurs  with  ob- 
struction at  different  levels  in   the  ureter.     Stone  at  the 


Fig.  221. — Ureteral  stone  (pyelogram  of  Fig.  220). 


ureterovesical  juncture  is  usually  attended  with  greater 
dilatation  than  when  it  is  situated  in  the  upper  ureter.  With 
stone  in  the  lower  ureter,  the  ureteral  dilatation  will  usually 
diminish  in  extent  as  the  ureter  nears  the  renal  pelvis.  It 
occasionally  happens  that  considerable  dilatation  is  visible 
in  the  ureterogram,  while  at  operation  the  ureter  may  appear 


238 


PYELOGRAPHY 


Fig.  222. — Ureteral  shadow. 


Fig.  223.— Ureteral  stone  (ureterogram  of  Fig.  222  partially  injected). 


URETERAL    STONE 


239 


to  be  but  slightly  enlarged.  This  is  to  be  explained  \jy  the 
great  degree  of  elasticity  in  the  ureteral  wall  which  may  per- 
mit the  ureter  to  return  nearly  to  its  normal  caliber  when  it 
is  not  distended.  In  Fig.  225  the  ureteral  dilatation  ap- 
parently gradually  ceases  at  about  the  level  of  the  third 


Fig.  224. — Ureteral  stone  (ureterogram  of  Fig.  222  more  fully  distended). 

lumbar  vertebra.     Above  this  point  the  ureter  as  well  as 
pelvis  are  normal  in  outline. 

With  stone  in  the  lower  ureter  the  renal  pelvis  is  fre- 
quently, though  not  always,  dilated  to  a  greater  or  less  ex- 
tent. Flattening  and  broadening  of  the  minor  calyces  and 
elongation  of  the  major  calyces  are  the  first  evidences  of 


240  PYELOGRAPHY 

ureteral  obstruction  visible  in  the  pelvic  outline.  The  dila- 
tation in  the  calyces  usually  remains  proportionately  larger 
than  that  in  the  true  pelvis.  When  the  lower  ureter  is  but 
partially  filled  by  the  injected  solution  and  its  outline  is  un- 
certain, the  existence  of  ureteral  dilatation  may  be  inferred 
from  evidence  of  dilatation  in  the  renal  pelvis,  a  fact  which 


Fig.  225. — Ureteral  dilatation  caused  by  stone  in  the  ureter. 

may  be  of  considerable  importance  in  the  identification  of 
shadows  in  the  lower  ureter. 

With  stone  in  the  lower  ureter,  considerable  ureteral  dila- 
tation may  be  present  with  little  or  no  change  in  the  out- 
line of  the  renal  pelvis.  However,  when  the  stone  is  in  the 
upper  ureter,  more  or  less  pelvic  dilatation  will  always  be 
seen.  Absence  of  changes  in  the  outline  of  the  renal  pelvis 
with  a  shadow  in  the  upper  ureter  would  demonstrate  its 


URETERAL   STONE  241 

extra-ureteral  nature.  In  Fig.  226  the  outline  of  the  peh'is 
is  normal  throughout,  although  considerable  dilatation  is 
apparent  in  the  lower  ureter  as  the  result  of  stone  (Figs.  210 
and  211). 

That  the  radiogram  may  occasionally  fail  to  show  the 
shadow  of  a  stone,  particularly  when  in  the  lower  ureter, 


Fig.  226. — Ureteral  stone  (pyelogram  of  Fig.  210). 

is  well  known.  In  case  of  a  negative  radiogram,  when  the 
clinical  and  cystoscopic  data  are  suggestive  of  stone  in  the 
ureter,  characteristic  dilatation  of  the  ureter,  as  demon- 
strated in  a  pyelo-ureterogram,  would  permit  the  diagnosis 
of  lithiasis.  A  small  stone  which  the  original  radiogram  has 
failed  to  show  will  occasionally  become  apparent  following 
a  pyelogram  because  of  absorption  of  the  colloidal  silver. 
16 


242  PYELOGRAPHY 

In  Fig.  227  the  lower  left  ureter  is  slightly  dilated  above  the 
ureterovesical  juncture.  The  original  radiogram  was  re- 
ported negative.  The  predominant  symptoms  were  re- 
peated colic  referred  to  the  left  kidney.  If  any  doubt 
arises  whether  the  lower  ureter  was  actually  dilated,  it 
would  be  removed  by  evidence  of  dilatation  in  the  pelvis, 
■as  demonstrated  in  Fig.  228.     Definite  dilatation  is  visible 


Fig.  227. — Ureteral  dilatation  caused  by  stone  (original  a-'ray  negative). 

only  in  the  calyces  as  the  result  of  the  mechanical  obstruc- 
tion caused  by  stone  which  is  probably  situated  in  the  ves- 
ical portion  of  the  ureter. 

The  portion  of  the  ureter  which  lies  in  the  bladder-wall 
will  not,  as  a  rule,  be  dilated  to  the  extent  of  the  ureter  im- 
mediately above.  Stone  in  the  intramural  portion  of  the 
ureter,  particularly  when  near  the  meatus,  usually  causes 
little  or  no  dilatation  in  that  portion  of  the  ureter.     The 


URETERAL   STONE 


243 


Fig.  228. — Ureteral  stone  (pyelogram  of  Fig.  227). 


Fig.  229. — Ureteral  shadow. 


244  PYELOGRAPHY 

characteristic  ureterogram  of  an  intramural  stone,  there- 
fore, would  show  an  area  of  undistended  ureter  extending 
above  the  stone  shadow  as  far  as  the  ureterovesical  juncture, 
beyond  which  it  becomes  abruptly  dilated.  In  Fig.  229 
a  stone-shadow  is  visible  in  the  region  of  the  left  lower 
ureter.     In  Fig.  230  the  outline  of  the  shadow  is  still  ap- 


Fig.  230. — Ureteral  stone  (ureterogram  of  Fig.  229). 

parent,  while  the  ureter  immediately  around  it  is  not  mark- 
edly dilated.  A  short  distance  above,  which  corresponds  to 
the  position  of  the  ureteropelvic  juncture,  the  ureter  is  well 
dilated.  The  stone  is  situated  in  the  vesical  portion  of  the 
ureter.  In  Fig.  231  a  shadow  is  visible  in  the  area  of  the 
left  lower  ureter.  In  Fig.  232  the  outline  of  the  dilated 
ureter  is  seen  above  the  original  shadow,  but  separated  from 


URETERAL   STONE 


245 


Fig.  231. — Ureteral  shadow. 


Fig.  232. — Ureteral  stone  (ureterogram  of  Fig.  231) 


246  PYELOGRAPHY 

it  by  a  distinct  break  in  its  outline.  This  is  due  to  the 
fact  that  the  stone  is  situated  in  the  intramural  portion  of 
the  ureter,  which  does  not  dilate  to  the  degree  of  the  ureter 
above  the  bladder-wall. 

Dilatation  of  the  Ureter  Below  the  Stone. — When  dila- 
tation of  the  ureter  is  visible  below  the  outline  of  the  stone, 


Fig.  233. — Ureteral  stone. 

it  is  usually  the  result  of  inflammatory  changes  in  the  ure- 
teral wall  subsequent  to  secondary  infection.  It  is  charac- 
terized by  a  uniform  enlargement  of  the  ureteral  lumen 
in  contrast  to  the  irregular  nodular  dilatation  which  ac- 
companies return  flow  of  the  injected  fluid.  Evidence  of 
inflammatory  dilatation  may  sometimes  be  the  only  evi- 


URETERAL   STOXE  247 

dence  of  the  existence  of  a  previous  infection.  Occasion- 
ally ureteral  dilatation  below  a  stone  shadow  may  have 
been  caused  by  mechanical  obstruction  of  a  stone  previously 
passed.  In  Fig.  233  the  dilatation  visible  in  the  outline  of 
the  ureter  below  the  stone  shadow  is  the  result  of  secondary 
infection. 

Immediate  Return  Flow. — Although  the  urine  may  flow 
by  a  stone  in  the  ureter  with  its  usual  volume,  it  is  peculiarly 
true  that  often  a  solution  injected  from  below  will  be 
unable  to  pass  beyond  the  stone.  Immediate  return  of  the 
injected  medium  at  the  site  of  a  suspected  shadow  identi- 
fies its  intra-ureteral  position.  It  may  occur  wdth  a  small  as 
well  as  a  large  stone,  and  at  any  portion  of  the  ureter.  It 
occurs  with  the  majority  of  stones  in  the  vesical  ureter, 
since  this  portion  of  the  ureter  does  not  dilate  as  does  the 
ureter  above.  Occasionally  a  slight  amount  of  injected 
solution  may  pass  beyond  the  shadow  and  may  appear  as  a 
diffuse  blur  in  the  ureter  above,  or  even  as  an  isolated  shadow 
in  the  renal  pelvis.  When  a  small  stone  in  the  ureter 
permits  no  injected  fluid  to  pass  by,  the  constriction  of  the 
ureteral  lumen  at  the  site  of  the  stone  is  frequently  caused 
by  secondary  inflammatory  stenosis.  The  demonstration  of 
immediate  return  flow  is  particularly  of  value  in  the  differ- 
entiation of  anatomic  from  pathologic  obstruction.  It  must 
be  remembered,  however,  that  with  obstruction  to  the 
ureteral  catheter  as  the  result  of  anatomic  conditions  in  the 
vesical  portion  of  the  ureter  it  may  occasionally  be  im- 
possible to  inject  any  fluid  beyond  the  obstruction.  In  Fig. 
233  two  stone  shadows  are  visible  in  the  right  kidney  area. 
The  lower  and  larger  of  the  two  is  situated  at  the  first  point 
of  narrowing  in  the  upper  ureter.     Below  it  the  dilated 


248  PYELOGRAPHY 

ureter  is  visible,  while  no  evidence  of  the  injected  solution 
is  apparent  above  the  stone  shadow. 

Extra-ureteral  Shadow. — The  relation  of  a  shadow  in  the 
area  of  the  ureter  to  an  opaque  ureteral  catheter  has  been 
generally  accepted  as  the  best  method  to  determine  whether 
the  shadow  is  intra-ureteral.  It  was  found,  however,  that  a 
shadow  may  be  extra-ureteral  and  still  appear  to  be  adjacent 


Fig.  234. — Extra-ureteral  shadows. 

to  the  outline  of  the  opaque  catheter.  Further  dilatation  in 
the  ureter  may  permit  a  shadow  to  be  at  a  distance  of  a  centi- 
meter from  the  outline  of  the  opaque  catheter  and  still  be 
within  the  ureter.  The  pyelo-ureterogram  has  been  found 
more  exact  than  the  opaque  catheter  in  the  recognition  of 
extra-ureteral  shadows.  Even  though  the  shadow  in  question 
is  in  direct  line  with  the  ureter,  if  the  outline  of  the  latter  is 
normal  throughout,  the  shadow  may  be  regarded  as  being 


URETERAL    STONE  249 

situated  outside  of  the  ureter.  In  Fig.  234  two  shadows  are 
visible  along  the  course  of  the  left  lower  ureter.  If  their 
relation  to  an  opaque  catheter  were  relied  upon,  one  would 
infer  that  the  shadows  were  both  intra-ureteral.  The  ab- 
sence of  any  dilatation  in  the  ureter,  however,  would  defin- 
itely determine  that  the  shadows  are  extra-ureteral.  In  Fig. 
235  a  shadow  suggestive  of  stone  is  visible  in  the  areas  of 


Fig.  235. — Extra-ureteral  shadows. 

both  right  and  left  lower  ureters.  That  these  shadows  are 
extra-ureteral  may  be  inferred  from  the  absence  of  dilatation 
in  the  course  of  the  ureter.  The  presence  of  a  normal  out- 
hne  in  both  upper  ureters  and  pelves  evident  in  Fig.  236 
would  corroborate  this.  In  Fig.  237  the  ureteral  catheter 
is  adjacent  to  an  apparent  stone  shadow.  The  normal  out- 
line of  the  pelvis  and  the  absence  of  dilatation  in  the  ure- 


250 


PYELOGRAPHY 


Fig.  236. — Extra-ureteral  shadows  (pyelo-ureterogram  of  Fig.  235). 


Fig.  237. — Extra-ureteral  shadow. 


URETERAL   STONE 


251 


ter,  however,  determine  the  extrarenal  nature  of  the  shadow. 
In  Fig.  238  the  shadow  in  the  right  ureter  area  is  apparently 


Fig.  238. — Extra-ureteral  shadow. 


adjacent  to  the  ureteral  catheter.  The  absence  of  any  di- 
latation in  either  pelvis  or  ureter  excludes  the  possibility  of 
a  ureter  stone. 


CHAPTER  IX 

RENAL  TUMOR 

A  CHANGE  in  the  nature  and  outline  of  the  renal  paren- 
chyma as  the  result  of  the  various  types  of  tumor  affects 
the  outline  of  the  renal  pelvis  to  a  variable  degree.  The 
tumor-forming  conditions  which  may  affect  the  pelvic  out- 
line are  neoplasm,  polycystic  kidney,  and  solitary  cyst. 

RENAL  NEOPLASM 

Of  the  different  types  of  tumor,  the  greatest  degree  of 
pelvic  deformity  will  usually  be  caused  by  neoplasm. 
Marked  deformity  of  the  renal  pelvis  is  visible  on  cross- 
section  of  a  kidney  with  tumor  involvement.  Although 
it  is  usually  impossible  to  differentiate  the  forms  of  neo- 
plasm by  the  changes  in  the  pelvic  outline,  the  most 
extensive  pelvic  deformity  will  accompany  sarcoma. 

Deformities  in  the  outline  of  the  renal  pelvis  resulting 
from  neoplasm  may  be  classified  as  follows : 

1.  Retraction  of  (a)  one  or  more  calyces  or  (6)  the  true 
pelvis. 

2.  Encroachment  on  the  pelvic  lumen  causing  (a)  flat- 
tening of  the  general  pelvic  outline,  (6)  narrowing  of  the 
individual  calyces,  and  (c)  obliteration  of  the  true  pelvis. 

3.  Secondary  necrosis. 

4.  Abnormal  position  of  the  renal  pelvis. 

5.  Deformity  at  the  ureteropelvic  juncture. 
Retraction   of   the    Calyces. — Probably   the   earliest   de- 
formity of  the  pelvis  resulting  from  renal  tumor  is  character- 

252 


RENAL   TUMOR 


253 


ized  by  a  retraction  of  one  or  more  calyces.  As  the  tumor 
enlarges  toward  the  periphery  it  retracts  the  calyx  involved 
with  it.  When  the  tumor  is  confined  to  either  pole  of  the 
kidney,  retraction  may  be  confined  to  the  adjacent  calyx. 
As  a  rule,  the  retraction  is  accompanied  by  distinct  narrow- 
ing of  the  lumen  of  the  calyx  and  effacement  of  its  terminal 


Fig.  239. — Normal  pelvis — elongated  calyx. 


irregularities.  It  should  be  remembered,  however,  that  in 
the  normal  pelvis  there  may  occasionally  be  one  or  more 
calyces  unusually  elongated.  Usually  the  general  contour 
of  the  major  calyx  and  the  irregularity  of  the  minor  calyces 
will  then  be  found  quite  normal.  Such  congenital  elonga- 
tions are  apt  to  occur  in  both  kidneys,  although  sometimes 


254 


PYELOGRAPHY 


it  is  found  in  but  one  side.  In  order  to  interpret  the 
pelvis  as  pathologic,  retraction  as  well  as  deformity  of 
the  calyx  must  be  well  marked.  In  Fig.  239  the  upper 
calyx  is  symmetrically  retracted  in  both  kidneys.  The 
outline  of  the  calyx  is  otherwise  normal,  and  the  terminal 
irregularities  are  well  retained.  In  Fig.  240  the  proximal 
calyx  is  curved  and  retracted  to  unusual  length,  its  lumen 


Fig.  240. — Renal  tumor — neoplasm. 

is  markedly  narrowed,  and  the  terminal  irregularities  are 
effaced.  At  operation  a  hypernephroma  was  found  in- 
volving the  upper  pole  of  the  kidney.  In  Fig.  241  the  upper 
calyx  is  so  narrowed  that  but  a  dim  curved  streak  remains. 
The  lateral  calyx  is  retracted  as  well  as  narrowed.  At  oper- 
ation a  hypernephroma  involving  the  upper  half  of  the  kid- 
ney was  found. 

The  number  of  calyces  involved  increases  with  the  size 


RENAL   TUMOR  255 

of  the  tumor.  With  retraction  of  multiple  calyces,  the 
larger  portion  of  the  kidney  is  usually  involved.  The 
calyces  may  be  retracted  to  unusual  lengths — sometimes  as 
far  as  four  or  five  inches.  This  will  occur  more  frequently 
with  large  tumors.  The  different  calyces  retracted  in  vari- 
ous directions  give  a  very  bizarre  appearance  in  the  pyelo- 
gram,  which  might  well  be  designated  as  a  ''spider-leg" 
deformity.     The  lumen  of  the  calyces  in  such  cases  may 


Fig.  241. — Renal  tumor — neoplasm. 

vary  considerably.  At  times  nodular  dilatation  is  visible 
in  their  course.  Again,  there  may  be  narrowing,  causing 
their  outUne  to  appear  as  irregular  narrow  streaks.  Should 
the  calyces  be  incompletely  filled,  their  dilated  portions 
alone  may  appear  in  the  plate.  As  a  result,  irregular 
shadows  may  be  seen  scattered  over  an  unusually  wide  kid- 
ney area.  In  Fig.  242  the  calyces  are  retracted  irregularly 
in  a  manner  peculiar  to  neoplasm.     While  the  calyces  are 


256 


PYELOGRAPHY 


generally  narrowed  as  well  as  extended,  in  areas  they  be- 
come retracted  laterally  and  are  irregularly  broadened. 
The  true  pelvis  is  relatively  small.  In  Fig.  243  the  calyces 
are  markedly  retracted.  The  upper  calyx  extends  from 
the  eleventh  rib  downward  parallel  to  the  spine  to  a  dis- 


Fig.  242. — Renal  tumor — neoplasm. 


tance  of  three  inches,  where  it  joins  the  other  calyces.  The 
caudal  calyx  extends  as  far  as  the  upper  surface  of  the  fifth 
lumbar  vertebra.  It  is  visible  as  a  narrow,  irregular  streak 
running  parallel  and  close  to  the  lateral  border  of  the  verte- 
bra.    The  middle  calyx  is  also  moderately  retracted  later- 


Fis-  243. — Renal  tumor — neoplasm. 


^^^ 


?^ 


17 


Fig.  244. — Renal  tumor — neoplasm. 
257 


258  PYELOGRAPHY 

ally.  The  true  pelvis  is  evidently  largely  obliterated.  In 
Fig.  244  the  irregular  narrow  streaks  which  extend  over  a 
large  area  in  the  right  kidney  region  outline  the  fine  crevices 
resulting  from  the  retraction  and  narrowing  of  the  calyces 
by  renal  neoplasm.  The  tumor  tissue  evidently  extends 
down  to  the  first  point  of  narrowing  of  the  ureter,  and  has 
largely  obliterated  the  true  pelvis.     In  Fig.  245  the  calyces 


Fig.  245. — Renal  tumor — neoplasm. 

in  the  left  pelvis  are  retracted  in  several  directions  and  are 
markedly  narrowed.  The  outline  of  the  true  pelvis  is  ir- 
regularly squared.  The  tumor  evidently  involves  the  en- 
tire kidney.     The  right  pelvis  is  normal  in  contrast. 

The  shadow  of  the  tumor  tissue  outlined  adjacent  to  that 
of  the  retracted  calyx  gives  additional  evidence  of  its  ab- 
normality. In  Fig.  246  the  shadow  of  the  tumor  tissue  is 
seen  adjacent  to  a  lateral  calyx,  which  extends  markedly 


RENAL   TUMOR  259 

narrowed    and    elongated.     The    lower    calyx   is   probably 
largely  effaced  by  the  tumor  tissue. 

The  drainage  of  the  injected  fluid  from  the  ends  of  the 
tumor-deformed  calyces  may  be  very  slow.  The  demonstra- 
tion of  the  opaque  medium  retained  in  the  calyces  for  more 
than  twenty-four  hours  after  the  pyelogram  is  made  may 
be  of  corroboratory  value  in  the  diagnosis  of  renal  tumor. 


Fig.  246. — Renal  tumor — neoplasm. 

A  single  small  area  of  the  injected  fluid  may  be  seen  at  some 
distance  from  the  true  pelvis.  In  Fig.  247  scattered  areas 
of  colloidal  silver  are  visible  over  the  right  kidney  area. 
The  plate  was  made  twenty-four  hours  subsequent  to  Fig, 
244,  and  demonstrates  the  slow  drainage  of  the  injected 
medium  which  occasionally  occurs. 

Encroachment  on  the  Pelvic  Lumen. — When  the  tumor 
involves  the  true  pelvis  to  any  great  extent,  the  usual  re- 


260 


PYELOGEAPHY 


suit  is  encroachment  on  the  pelvic  lumen.  With  a  moderate 
degree  of  involvement  but  one  portion  of  the  pelvis  may  be 
invaded;  with  general  involvement  of  the  kidney,  either 
irregular  narrow  spaces  may  remain  or  total  obliteration  of 
the  true  pelvis  may  result.  In  case  of  the  latter,  no  evi- 
dence of  the  injected  medium  would  be  found  in  the  kidney 
area,  but  it  would  be  seen  extending  as  far  as  the  uretero- 


Fig.  247. — Renal  tumor — neoplasm. 

pelvic  juncture,  ending  with  a  more  or  less  irregular  shadow. 
The  tumor  tissue  may  extend  down  into  the  upper  ureter  to 
a  variable  extent,  indicated  by  the  outline  of  the  ureter 
remaining.  In  Fig.  248,  as  the  result  of  complete  invasion 
by  the  neoplasm,  there  is  no  evidence  of  a  pelvic  outline. 
The  outline  of  the  upper  ureter  is  seen  to  be  irregular  and 
evidently  filled  with  tumor  tissue  for  a  distance  of  several 


RENAL   TUMOR 


261 


^ 


Fig.  248. — Renal  tumor — neoplasm. 


Fig.  249. — Renal  tumor — neoplasm. 


262 


PYELOGRAPHY 


Fig.  250. — Renal  tumor — neoplasm  (post-operative  specimen). 


Fig.  251. — Renal  tumor — neoplasm. 


RENAL   TUMOR 


2()3 


inches  below  the  pelvis.  In  Pig.  249  the  few  irregular 
streaks  indicate  the  crevices  remaining  in  the  pelvis  as  the 
result  of  invasion  by  tumor  tissue.  In  Fig.  250,  which  was 
taken  in  a  postoperative  specimen,  the  tumor  has  invaded 
the  renal  pelvis  to  such  an  extent  that  in  one  portion  but  a 
few  irregular  narrow  crevices  remain.     The  outline  of  the 


Fig.  252. — Renal  tumor — neoplasm. 


tumor  tissue  is  apparent  in  the  lower  pole.  In  Fig.  251  a 
few  irregular  shadows  are  seen  scattered  in  the  right  kidney 
area  which  represent  markedly  retracted  and  narrow  calyces. 
The  true  pelvis  is  represented  by  an  irregular  streak,  and 
the  upper  ureter  is  irregularly  retracted  and  dilated  and 
is  displaced  over  the  vertebra  as  the  result  of  tumor  en- 
croachment.    The  streaks  visible  in  the  left  kidney  area  are 


264  PYELOGRAPHY 

caused  by  intestinal  shadows  and  might  be  confused  with 
those  of  scattered  colloidal  silver. 

When  the  tumor  tissue  grows  toward  the  pelvis  from 
either  pole,  it  may  encroach  upon  the  outline  of  the  true 
pelvis  so  as  to  flatten  it.  In  such  cases  one  or  several  of  the 
calyces  may  be  narrowed  without  retraction.  In  Fig.  252 
the  outline  of  the  tumor  tissue  may  be  made  out  as  a  large, 


Fig.  253. — Renal  tumor — neoplasm. 

dim,  rounded  shadow  adjacent  to  and  extending  below  the 
true  pelvis.  The  pelvic  outline  is  diminished  in  size  and  is 
flattened  along  its  lower  border.  The  lower  major  calyx 
is  so  flattened  and  narrowed  as  to  form  a  crescent-shaped 
streak  in  keeping  with  the  contour  of  the  tumor  shadow. 

Dilatation  of  the  True  Pelvis. — Occasionally,  instead  of 
encroachment,  irregular  dilatation  of  the  true  pelvis  may 
result  either  from  retraction  or  from  necrosis  of  the  surround- 


RENAL   TUMOR  265 

ing  tissue.  The  condition  may  occasionally  be  inferred  by 
determining  the  presence  of  residual  urine  in  the  pelvis  or 
by  the  introduction  of  25  or  30  c.c.  of  fluid  into  the  dilated 
pelvis  before  causing  pain.  Dilatation  will  occur  more 
frequently  with  carcinoma,  since  the  condition  tends  to 
destroy  the  tissues  without  retraction  of  the  calyces.  In 
Fig.  253  the  outline  of  the  true  pelvis  is  irregularly  cylindric. 


Fig.  254. — Renal  tumor — neoplasm. 

The  calyces  are  largely  effaced.  The  ureteropelvic  juncture 
is'  situated  at  the  upper  portion  of  the  pelvis.  At  opera- 
tion a  large  carcinoma  of  the  kidney  was  found.  In  Fig. 
254  the  irregular  area  is  suggestive  of  necrotic  areas  fre- 
quently seen  with  extensive  pyonephrosis.  At  operation  a 
diffuse  carcinoma  with  considerable  necrosis  and  secondary 
infection  of  the  pelvis  was  found. 

Abnormal  Position  of  the  Renal  Pelvis. — Since  the  normal 


266  PYELOGRAPHY 

excursion  of  the  kidney  may  be  considerable,  the  demon- 
stration of  a  low-lying  pelvis  alone  would  not  necessarily 
be  indicative  of  a  pathologic  renal  condition.  Marked 
lateral  or  median  displacement  of  the  pelvic  outline,  how- 
ever, is  frequently  caused  by  some  abnormal  condition.     A 


Fig.  255. — Renal  tumor — neoplasm. 

tumor  in  the  kidney  may  grow  so  as  to  cause  considerable 
displacement  of  the  pelvic  outline.  As  a  rule,  in  such  cases 
deformity  of  the  pelvis,  characterized  by  elongation  and 
flattening  of  the  general  contour  of  the  pelvis,  as  well  as  of 
the  calyces,  will  also  be  present.     It  must  be  remembered, 


RENAL   TUMOR  267 

however,  that  extrarenal  tumor  may  also  cause  lateral  or 
median  displacement.  This  usually  occurs  to  a  lesser 
extent  than  with  renal  tumor,  and  the  contour  of  the 
pelvis  will  be  normal. 

In  Fig.  255  the  pelvis  is  displaced  upward  as  far  as  the 


Fig.  256. — Renal  tumor — neoplasm. 

lower  border  of  the  tenth  rib,  and  laterally  at  an  abnormal 
distance  from  the  vertebrae.  Such  a  tumor  would  mani- 
festly be  difficult  to  palpate.  The  outline  of  the  true 
pelvis  is  irregularly  elongated  and  narrow  as  the  result  of 
tumor  compression.     The  calyces  are  flat  and  broad,  while 


268  PYELOGRAPHY 

the  terminal  irregularities  are  largely  effaced.  In  Fig. 
256  marked  median  displacement  of  the  pelvis  is  demon- 
strated. The  pelvic  outline  overlies  the  first  and  second 
lumbar  vertebrae,  and  in  fact  merges  with  their  shadows. 
The  calyces  are  elongated  and  irregularly  narrowed  in  a 
manner  which  is  characteristic  of  tumor  deformity.  The 
outline  of  the  tumor  tissue  extends  laterally  and  caudad 
from  the  pelvis  as  a  large  rounded  hazy  shadow  as  far  as  the 
crest  of  the  ilium. 


Fig.  257. — Renal  tumor — neoplasm. 

Deformity  at  the  Ureteropelvic  Juncture  and  Upper 
Ureter. — When  the  tumor  involves  the  pelvis  to  a  consider- 
able extent,  it  may  also  encroach  upon  the  adjacent  portion 
of  the  ureter.  As  in  the  pelvis,  such  involvement  may 
either  cause  retraction  of  the  walls  of  the  ureter  or  oblitera- 
tion of  its  lumen.  With  tumor  retraction  of  the  upper  ureter 
its  lumen  is  usually  of  the  same  size  and  merges  with  that  of 


RENAL   TUMOR  2(39 

the  true  pelvis.  In  Fig.  257  the  pelvic  outline,  although 
dim,  is  irregularly  squared,  the  lower  calyx  being  effaced. 
The  upper  ureter  is  unusually  wide  as  the  result  of  retrac- 
tion of  the  surrounding  tumor  tissue  for  a  short  distance  be- 
low the  ureteropelvic  juncture. 

If  the  ureter  is  involved  by  invading  tumor  tissue,  its  out- 
line becomes  obliterated  to  the  extent  of  the  tumor  invasion. 


Fig.  258. — Pelvic  deformity  simulating  renal  tnmor. 

Occasionally  a  blood-clot  may  coagulate  in  the  pelvis  and 
upper  ureter  and  simulate  tumor  involvement.  In  case  of 
partial  obliteration  by  either  blood-clot  or  tumor,  the  re- 
maining space  would  be  demonstrated  by  irregular  streaks. 
In  Figs.  258  and  259  the  pelvic  outline  is  obliterated,  while 
that  of  the  ureter  is  visible  as  an  irregular  spiral  shadow  ex- 
tending from  a  point  several  inches  below  the  ureteropelvic 
juncture  to  the  upper  portion  of  the  sacrum.     The  peculiar 


270  PYELOGEAPHY 

outline  was  due  to  a  blood-clot  which  obliterated  the  lumen 
of  the  pelvis  and  first  portion  of  the  ureter  and  partially 
filled  the  portion  of  the  ureter  outlined  by  the  spiral  shadow. 
At  operation  the  pelvis  and  ureter  were  found  moderately 
distended  by  a  well-coagulated  blood-clot.     The  kidney  ap- 


Fig.  259. — Ureteral  deformity  simulating  tumor. 

peared  to  be  normal  on  exploration  and  the  hematuria  was 
evidently  of  the  so-called  essential  type. 

Occasionally  the  tumor  tissue  may  displace  the  upper 
ureter  to  a  considerable  extent  without  otherwise  involv- 
ing it.     In  such  cases  displacement  is  more  often  median. 


RENAL   TUMOR 


271 


The  ureter  would  then  appear  curved  by  evident  adjacent 
tumor  tissue  over  the  vertebral  column.  In  Fig.  260,  while 
the  distribution  and  size  of  the  two  calyces  are  unusual, 
typical  tumor  deformity  is  not  apparent.  The  true  pelvis 
and  ureteropelvic  juncture  are,  however,  situated  unusually 


Fig.  260. — Renal  tumor — ureteral  displacement. 


near  the  vertebrae,  while  the  upper  ureter  is  displaced  medi- 
ally so  as  to  lie  over  them. 

Sources  of  Error. — Many  difficulties  may  arise  to  pre- 
vent obtaining  a  successful  pyelogram  in  the  case  of  tumor. 
The  possible  sources  of  error  in  making  the  pyelogram  are 
as  follows:  (1)  Errors  resulting  from  faulty  pyelographic 
technic ;    (2)  obstruction  to  the  ureteral  catheter  from  vari- 


272  PYELOGRAPHY 

ous  abnormalities  in  the  course  of  the  ureter,  extrarenal 
pressure  upon  the  ureter,  or  ureteric  metastasis;  (3)  the 
inability  sufficiently  to  distend  the  pelvis  of  the  kidney  and 
ureter  because  of  immediate  return  of  fluid;  (4)  dilution  of 
the  injected  fluid  by  means  of  retained  fluid  in  the  pelvis; 

(5)  obscuring  of  the  pelvic  outline  by  overlying  tumor  tissue ; 

(6)  error  in  interpretation. 


Fig.  261. — Pelvic  deformity  simulating  renal  tumor. 

With  marked  renal  colic  at  the  time  of  examination  the 
subsequent  contraction  of  the  pelvis  might  leave  an  ir- 
regular outline  which  might  easily  be  confused  with  the 
encroachment  of  tumor  tissue.  In  Fig.  261  the  renal  pelvis 
is  represented  by  an  irregular  streak  in  the  center  of  a  dim 
shadow  which  was  interpreted  to  be  the  outline  of  the  kid- 
ney. After  carefully  injecting  3  c.c.  of  fluid,  the  patient 
complained  of  severe  renal  pain.  The  pyelogram  was  made 
immediately  after,  and  the  contracted  pelvic  outline  is  evi- 


RENAL   TUMOR  273 

dently  physiologic  as  the  result  of  pain.  At  operation,  a 
greatly  distended  gall-bladder  was  found  to  overlie  a  normal 
kidney. 

If  a  normal  pelvis  with  a  long  normal  calyx  is  incompletely 
filled,  a  detached  shadow  might  give  the  appearance  of  a 
retracted  calyx.  A  detached  shadow  of  a  retracted  calyx 
incompletely  filled  might  also  simulate  that  caused  by  stone. 
Therefore  a  preliminary  plate  of  every  tumor  should  be  made 
first  to  exclude  the  possibility  of  lithiasis. 

It  will  not  be  possible  to  make  pyelographic  demonstra- 
tion of  pelvic  deformity  in  every  neoplasm.  \Mien  the 
tumor  is  small  or  confined  to  one  pole,  it  often  will  not  cause 
enough  deformity  to  be  of  diagnostic  value.  Practically 
every  tumor  involving  more  than  one-third  of  the  kidney 
will  have  recognizable  deformity.  A  comparatively  small 
tumor,  when  situated  adjacent  to  the  pelvis,  may  also  cause 
marked  deformity.  Again,  the  tumor,  when  situated  at  some 
distance  from  the  pelvis,  may  attain  considerable  size  and 
cause  little  or  no  deformity.  Interstitial  hypernephroma, 
unless  advanced  to  a  marked  degree,  should  cause  no  de- 
formity. 

Obstruction  to  the  ureteral  catheter  at  or  below  the  pelvic 
juncture  may  be  a  source  of  confusion.  Such  obstruction 
would  not  necessarily  indicate  a  palpable  abdominal  tumor 
on  that  side  to  be  intrarenal.  Obstruction  met  by  the 
ureteral  catheter  in  the  upper  ureter  may  be  physiologic, 
or  it  may  be  due  to  pressure  from  extra-ureteral  or  extra- 
renal tumor.  If  the  pyelogram  shows  that  little  or  no  fluid 
can  pass  such  an  obstruction,  it  may  be  inferred  that  the 
obstruction  is  pathologic  and  is  either  in  the  ureter  or  in  the 
kidney. 

Contra-indications  to   Pyelography. — (1)    If  it  is  evident 
18 


274  PYELOGRAPHY 

from  the  cystoscopic  examination  that  renal  tumor  is  pres- 
ent, pyelography  should  not  be  employed,  since,  as  has  been 
described,  the  silver  solution  may  act  as  an  irritant  when- 
ever its  drainage  is  interfered  with.  (2)  A  pyelogram  should 
not  be  made  in  case  of  tumor  when  the  patient  is  markedly 
emaciated  or  weakened.  The  possible  irritation  from  the 
cystoscopic  examination  alone,  not  to  mention  that  derived 
from  ureteric  catheterization  and  injection  of  colloidal  silver, 
may  suffice  to  hasten  the  patient's  death. 

Differential  Diagnosis. — The  identification  of  tumor  in 
the  upper  lateral  abdomen  by  means  of  palpation  is  uncer- 
tain, since  what  may  appear  on  palpation  to  be  renal  tumor 
may  prove  at  operation  to  be  tumor  of  a  perirenal  organ. 
Not  infrequently  tumor  may  be  palpated  in  the  lateral  ab- 
domen, which,  from  the  clinical  data,  will  not  be  regarded 
as  renal,  but  which  at  operation  is  found  to  involve  the  kid- 
ney. On  the  other  hand,  if  the  tumor  involves  the  upper 
pole  in  a  high-lying  kidney  and  the  abdomen  is  very  large 
or  muscular,  it  frequently  cannot  be  definitely  palpated, 
even  though  it  may  be  of  considerable  size.  Further,  a  large, 
low-lying  kidney  may  on  palpation  appear  abnormally  large 
and  suggestive  of  tumor.  Congenital  conditions,  such  as 
renal  torsion,  pelvic  and  fused  kidneys,  may  be  the  cause  of 
the  evident  abdominal  tumors  best  identified  by  means  of 
pyelography.  If  a  tumor  can  be  demonstrated  in  the  pyelo- 
gram where  palpation  is  of  doubtful  value,  the  diagnosis  is 
certain,  while  a  normal  pelvic  outline  to  a  great  extent 
excludes  renal  involvement. 

It  may  be  difficult  to  identify  clinically  a  closed  renal 
tumor.  The  three  more  common  forms,  e.  g.,  pyonephrosis, 
neoplasm,  and  hydronephrosis,  may  occasionaUy  be  diffi- 
cult to  differentiate  on  cystoscopic  examination,  particularly 


RENAL   TUMOR  275 

when  an  impassable  obstruction  is  found  in  the  upper  ureter. 
Although  none  of  the  injected  fluid  may  enter  the  pelvis, 
the  outline  of  the  ureter  below  it  may  be  of  differential  value. 
A  dilated  ureter  from  ureteritis  indicates  chronic  infection 
and  is  to  be  expected  with  inflammatory  tumors.  With  an 
outline  of  a  small  ureter  below  the  tumor,  the  existence  of 
neoplasm  may  be  inferred,  since  the  ureter  may  become 
atrophied  from  disuse. 

Pyelography  is  of  considerable  value  in  determining  the 
cause  of  renal  hematuria  in  which  the  etiologic  factor  can- 
not be  otherwise  ascertained.  In  the  differential  diagnosis 
of  obscure  neoplasm  and  chronic  infection  with  hematuria, 
it  may  be  the  only  method  available.  The  demonstration 
of  a  normal  pelvis  in  a  case  of  hematuria  is  of  definite  value 
in  the  identification  of  the  so-called  essential  hematuria. 
It  is  particularly  useful  in  the  identification  of  abdominal 
tumor,  where  the  previous  history  of  hematuria  has  been 
indefinite  or  uncertain  and  where  an  examination  of  the 
urine  is  negative  or  shows  but  few  microscopic  elements 
present.  With  complete  clinical  and  cystoscopic  data,  the 
differential  diagnosis  of  hematuria  occurring  with  hydro- 
nephrosis, renal  neoplasm,  or  infection  is  usually  not  diffi- 
cult. Occasionally,  however,  the  pyelogram  may  be  the 
only  method  whereby  a  diagnosis  can  be  made.  In  Fig. 
262  no  evidence  of  the  pelvic  outline  is  visible.  The  out- 
line of  the  ureter  is  apparent  as  far  as  the  ureteropelvic 
juncture,  where  it  abruptly  ends.  In  case  of  tumor  the 
outline  of  the  upper  ureter  would  be  more  diffuse  and  ir- 
regular, depending  upon  the  degree  of  ureteral  invasion  by 
the  tumor  tissue.  In  case  of  closed  pyonephrosis  a  greater 
degree  of  ureteral  dilatation  would  be  expected.  The  pa- 
tient's subjective  symptoms  were  largely  those  of  repeated 


276  PYELOGEAPHY 

hematuria  and  finding  of   tumor.     At   operation  a  large 
closed  hydronephrosis  was  found. 

TUMOR  OF  THE  RENAL  PELVIS 
When  a  tumor  originates  within  the  pelvis  itself,  it  will 
naturally  occlude  its  lumen  to  a  variable  degree,  depending 
upon  the  nature  of  the  neoplasm.     The  majority  of  such 


Fig.  262. — Renal  tumor — closed  hydronephrosis. 

tumors  being  malignant,  the  outline  of  the  pelvic  wall  will 
be  markedly  altered.  If  the  growth  is  papillomatous,  the 
pelvic  lumen  will  be  obliterated  to  a  variable  degree,  caus- 
ing an  irregular,  narrow  outline  in  the  pyelogram.  As  would 
be  expected,  the  greater  deformity  would  be  found  in  the 
true  pelvis.  The  calyces  would  not  be  retracted  nor  neces- 
sarily obliterated,  as  occurs  with  tumor  originating  in  the 
kidney  substance. 


RENAL   TUMOR  277 

Angiomatous  change  of  a  papilla  or  a  small  papilloma 
would  not  necessarily  cause  recognizable  deformity.  Villous 
proliferation  of  the  mucosa  as  the  result  of  a  chronic  inflam- 
mation in  the  pelvis  would  be  accompanied  by  the  changes 
in  outline  characteristic  of  the  latter  condition. 

EXTRARENAL  TUMOR 

While  the  radiographic  shadow  of  extrarenal  tumor  tissue 
in  its  relation  to  that  of  the  kidney  may  frequently  be  of 
value  in  identifying  an  extrarenal  tumor,  it  cannot  always  be 
relied  upon.  More  often  the  outline  of  the  tumor-mass  is 
indistinctly  defined  and  obscurely  merged  with  a  more  or 
less  indefinite  renal  shadow.  If,  however,  the  renal  pelvis 
is  demonstrated  in  the  pyelogram,  with  a  normal  outline 
lying  at  some  distance  or  in  impossible  relationship  to  an 
adjoining  tumor  shadow,  its  extrarenal  nature  may  be  defi- 
nitely ascertained.  In  Fig.  263  the  outline  of  a  normal  renal 
pelvis  is  seen  lying  at  some  distance  median  to  the  outline 
of  an  extrarenal  tumor.  Although  the  renal  outline  as  well 
as  that  of  the  tumor  is  fairly  distinct,  the  outline  of  the  pelvis 
is  normal  and  too  far  distant  from  the  tumor  shadow  to  per- 
mit the  latter  to  be  intrarenal. 

The  outline  of  the  tumor-mass  may  be  situated  on  a  line 
with  the  kidney,  and  the  pelvic  outline  then  appears  to  be 
within  it.  If  the  outline  of  the  renal  pelvis  is  normal,  the 
probability  of  the  surrounding  tumor  being  of  renal  origin 
would  be  slight.  Confusion  might  arise  in  interpretation 
when  an  unusually  small  pelvis  or  one  with  anomalous 
branching  and  arrangement  of  calyces  lies  in  the  center  of  a 
shadow  of  a  possible  renal  tumor.  In  Fig.  261  a  distended 
gall-bladder  cast  a  shadow  simulating  that  of  a  possible 
renal  tumor.     In  the  center  of  this  shadow  is  seen  a  narrow 


278  PYELOGEAPHY 

streak,  which  might  easily  be  mistaken  for  a  deformed  renal 
pelvis.  In  this  case,  however,  it  represents  a  small  pelvis  in 
a  state  of  marked  contraction  as  a  result  of  overdistention. 
Displacement  of  the  pelvic  outline  may  be  caused  by 
pressure  from  extrarenal  tumor.  As  a  rule,  it  is  more  mod- 
erate in  degree  than  that  caused  by  renal  tumor.  Retro- 
peritoneal tumor  will  probably  cause  the  greatest  degree  of 


Fig.  263. — Extrarenal  tumor. 

change  in  position.  Displacement  of  the  upper  ureter 
will  usually  be  slight,  even  though  the  position  of  the  kid- 
ney is  changed.  Although  pressure  by  extrarenal  tumor  will 
not  often  cause  much  change  in  the  outline  of  the  pelvis, 
occasionally  it  may  flatten  it  to  a  moderate  degree. 

POLYCYSTIC  KIDNEY 
Abnormality  in  the  pelvic  outline  accompanying  poly- 
cystic kidney  will  not  be  apparent  in  the  pyelogram  as  fre- 


RENAL   TUMOR 


279 


quently  as  with  renal  neoplasm.  It  was  present  in  but  12 
of  the  21  cases  of  polycystic  kidney  where  a  pyelogram  was 
made.  The  changes  in  the  outline  of  the  renal  pelvis  which 
may  occur  with  polycystic  kidney  are  as  follows:  (1)  Short- 
ening or  obliteration  of  one  or  more  of  the  calyces,  giving 
the  pelvic  outline  an  oval  or  irregularly  squared  contour; 
(2)  broad,  irregular  retraction  of  the  calyces;    (3)  change  in 


Fig.  264-. — Renal  tumor — polycystic  kidney. 


position  and  axis  of  the  pelvis;    (4)  inflammatory  changes 
consequent  to  secondary  infection. 

Obliteration  of  the  calyces  may  be  confined  to  but  one 
portion  of  the  pelvis,  leaving  one  or  more  calyces  well  out- 
lined. The  partial  or  complete  obliteration  of  the  calyces 
is  caused  by  the  encroachment  of  the  cortical  cysts.  As  a 
rule,  the  degree  of  deformity  increases  with  the  size  and 
number  of  the  cysts.     Occasionally  only  the  remnant  of  one 


280 


PYELOGKAPHY 


calyx  will  remain,  giving  the  outline  of  the  pelvis  a  peculiar 
rounded  form;  again,  the  encroachment  of  the  cysts  may 
affect  all  the  calyces  and  so  compress  the  pelvis  as  to  give  it  a 
cylindric  outline.  Complete  obliteration  of  the  pelvis  it- 
self, such  as  occurs  with  neoplasm,  would  hardly  be  possible. 
In  Fig.  264  the  outline  of  the  true  pelvis  is  oval.     The  calyces 


Fig.  265. — Renal  tumor — polycystic  kidney. 


are  dimly  outlined  and  almost  obliterated.  The  pelvic 
outline  is  typical  of  polycystic  kidney.  In  Fig.  265  the 
right  pelvis  is  displaced  downward  and  median.  The  out- 
line of  the  true  pelvis  is  irregularly  oblong,  and  the  calyces 
are  largely  obliterated.  The  course  of  the  ureter  may  be 
observed  extending  over  the  vertebral  column  as  a  curved 
dim  streak.     It  is  evidently  displaced  by  the  cystic  enlarge- 


RENAL   TUMOR 


281 


ment  in  the  lower  pole  of  the  kidney.  In  Fig.  2(30  the  left 
pelvis  is  markedly  compressed  by  the  multiple  cysts,  so 
that  but  a  narrow  streak  remains.  The  calyces  are  com- 
pletely obliterated,  and  the  true  pelvis  markedly  flattened 
and  elongated.  Upward  and  lateral  displacement  of  the 
kidney  is  evident.     The  right  pelvis  shows  abbreviation  of 


Fig.  266. — Renal  tumor — polycystic  kidney. 


the  calyces,  but  increase  in  size  of  the  true  pelvis,  so  as  to 
simulate  a  moderate  degree  of  hydronephrosis. 

Retraction  of  the  calyces  as  the  result  of  polycystic  growth 
occurs  less  frequently  than  with  neoplasm.  When  it  does 
occur,  the  retraction  causes  broad  spaces  in  contrast  to  the 
narrow  streaks  typical  of  neoplasm.  At  times  the  calyx 
retraction  occurring  in  the  polycystic  kidney  may  be  so 
broad  and  irregular  in  outline  as  to  suggest  pyonephrosis. 


282 


PYELOGRAPHY 


The  absence  of  pus  in  the  urine  and  of  inflammatory  dila- 
tation in  the  outhne  of  the  ureter,  however,  should  exclude 
the  inflammatory  nature  of  the  pelvic  deformity.  In  Fig. 
267  marked  deformity  of  the  pelvic  outline  is  visible.  The 
calyces  are  widely  retracted  and  broadened  throughout; 
their  outline  is  suggestive  of  pyonephrosis,  but  the  absence 
of  any  evidence  of  infection  in  the  urine  would  exclude  in- 


Fig.  267. — Renal  tumor — polycystic  kidney. 

flammatory  dilatation.  At  operation  a  polycystic  kidney 
was  found.  In  Fig.  268  the  calyces  are  retracted  to  a  more 
moderate  degree  and  are  irregularly  broadened  at  their 
apices.  At  operation,  marked  polycystic  formation  was 
discovered. 

Secondary  infection  will  not  infrequently  cause  the  patient 
with  polycystic  kidney  to  consult  a  surgeon.  The  inflam- 
matory changes  consequent  to  secondary  infection  in  poly- 


RENAL   TUMOR 


283 


Fig.  268. — Renal  tumor — polycystic  kidney. 


Fig.  269. — Renal  tumor — polycystic  kidney. 


284  PYELOGRAPHY 

cystic  kidney  will  vary  considerably  in  extent.  As  a  rule, 
cortical  areas  are  more  irregular  and  larger  in  extent  than  is 
usually  seen  with  the  uncomplicated  inflammatory  pelvic 
dilatation.  The  recognition  of  the  actual  condition  may  be 
difficult,  however,  and  the  pelvic  outline  may  easily  be  con- 
fused with  that  of  pyonephrosis.  In  Fig.  269  an  irregular 
pelvic  outline  is  visible  on  both  sides.  Although  incompletely 
distended,  the  calyces,  particularly  in  the  left  pelvis,  are 
dilated  as  the  result  of  inflammatory  change  and  their  out- 
lines are  suggestive  of  pyonephrosis.  Cystoscopic  examina- 
tion demonstrated  infected  urine  from  that  kidney.  Surgical 
exploration  revealed  a  polycystic  kidney,  with  secondary 
infection  and  tissue  degeneration. 

Encroachment  upon  the  calyces  and  pelvis  by  large  cysts 
may  cause  a  change  in  the  relative  position  of  the  pelvis. 
As  a  result,  the  pelvic  outline  may  either  be  displaced  to 
unusual  situations  or  its  axis  may  extend  horizontally  or 
even  caudad  instead  of  upward,  as  in  the  normal.     In   Fig. 

264  the  axis  of  the  pelvis  extends  horizontally  and  down- 
ward instead  of  in  the   usual   upward  direction.      In   Fig. 

265  the  pelvis  is  displaced  toward  the  median  line  and  down- 
ward as  the  result  of  polycystic  change.  The  axis  of  the 
pelvis  is  horizontal  and  slightly  caudad. 

In  one  case  which  came  under  observation  a  large  cyst 
had  ruptured  into  the  pelvis  of  the  kidney.  The  ruptured 
cyst  was  only  partially  filled  with  the  injected  medium,  and 
consequently  the  resulting  outline,  although  rather  indefi- 
nite, was  suggestive  of  hydronephrosis.  In  another  case 
of  polycystic  kidney  the  kidney  was  ruptured  through 
trauma  some  months  prior  to  examination.  In  the  pyelo- 
gram  indistinct  areas  of  the  opaque  medium  were  widely 
scattered,   suggestive   of   diffuse  retraction  of   the   calyces 


RENAL   TUMOR 


285 


usually  seen  with  neoplasm.     Similar  deformity  may  often 
be  seen  with  the  usual  ruptured  kidney. 

The  existence  or  degree  of  the  pelvic  deformity  will  not 
necessarily  be  dependent  upon  the  size  of  the  kidney  ex- 
amined. When  with  polycystic  kidney  one  kidney  only  is 
markedly  enlarged,  on  palpation  the  deformity  is  occasion- 
ally found  greater  in  the  pyelogram  of  the  kidne}^  which 
could  not  be  palpated. 


Fig.  270. — Renal  tumor — solitary  cyst. 


SOLITARY  CYST 

A  not  infrequent  cause  of  symptomless  abdominal  tumor 

is  a  large  solitary  renal  cyst.     The  urinary  and  cystoscopic 

data  may  be  negative  and  the  nature  of  the  tumor  remain 

unrecognized.     When  the  cyst  becomes  so  large  or  is  so  situ- 


286 


PYELOGRAPHY 


ated  as  to  compress  the  pelvis,  the  resulting  deformity  may 
be  outlined  in  the  pyelogram.  A  large  cyst  may  cause  con- 
siderable change  in  the  position  and  axis  of  the  kidney, 
possibly  as  the  result  of  increased  weight  in  one  pole.  In 
Fig.  270  marked  compression  by  a  large  solitary  cyst  in- 
volving the  entire  lower  pole  and  part  of  the  upper  is  ap- 


Fig.  271. — Renal  tumor — solitary  cyst. 


parent.  The  outline  of  the  pelvis  is  cylindric,  and  is  similar 
to  that  seen  with  polycystic  kidney.  Only  the  upper  calyx, 
which  is  abbreviated,  remains.  The  upper  portion  of  the 
ureter  is  displaced  medially  to  a  moderate  degree.  In  Fig. 
271  the  direction  of  the  pelvic  axis  is  displaced  horizontally 
and  caudad  and  appears  to  be  pulled  downward.  The  change 
in  position  was  the  result  of  a  large  solitary  cyst  involving 


RENAL   TUMOR 


287 


the  lower  pole.  In  Fig.  272  the  anomalous  position  of  the 
pelvis  and  arrangement  of  its  calyces  were  due  to  pressure 
from  an  adjacent  Wolffian  cyst.  The  pelvis  was  displaced 
laterally  by  the  intervening  cyst,  which  also  caused  the  kid- 
ney to  rotate  partially. 


Fig.  272. — Renal  tumor — cyst. 


THE  URETER 
Renal  neoplasm,  particularly  when  involving  the  lower 
pole  and  the  lower  portion  of  the  pelvis,  may  involve  the 
first  portion  of  the  ureter  and  retract  it  to  a  varying  degree. 
The  ureter  may  also  dilate  because  of  mechanical  obstruc- 
tion caused  by  pressure  from  extra-ureteral  tumor.  Such 
obstruction  is  frequently  observed  with  various  pelvic 
tumors.  In  Fig.  257  the  pelvis  is  so  encroached  upon  that 
but  a  small  space  remains.     The  upper  ureter  is  dilated  to  a 


288  PYELOGRAPHY 

short  distance  beyond  the  ureteropelvic  juncture  by  the 
surrounding  tumor  tissue. 

When  a  retroperitoneal  or  abdominal  tumor  involves  the 
ureteral  wall,  it  may  become  retracted  or  constricted  by  ad- 


Fig.  273. — Tumor  involving  ureter. 

jacent  tumor  tissue,  similarly  to  the  renal  pelvis.  Such 
ureteral  retraction  will,  as  a  rule,  be  irregularly  localized. 
In  Fig.  273  a  retroperitoneal  sarcoma  involved  the  lower 
third  of  the  ureter,  causing  irregularly  localized  dilatation. 


CHAPTER  X 

CONGENITAL  ANOMALY 

The  clinical  diagnosis  of  congenital  anomaly  in  the  kid- 
ney and  ureter  was  first  rendered  possible  bj^  the  introduction 
of  the  shadow-casting  ureteral  catheter.  The  relative 
position  of  the  two  renal  pelves,  the  course  of  the  ureter, 
and  the  existence  of  dupUcation  of  the  ureter  or  pelvis  could 
frequently  be  rendered  visible  in  the  radiogram  after  intro- 
ducing an  opaque  catheter  into  the  parts  in  question. 
With  the  development  of  pyelography,  however,  additional 
and  more  accurate  data  were  acquired  in  the  exact  diagnosis 
of  congenital  anomaly.  By  its  means  we  are  able  to  ascer- 
tain the  existence  of  congenital  anomaly  which  cannot  be 
ascertained  by  the  opaque  catheter  alone,  and  the  existence 
and  nature  of  pathologic  conditions  which  may  comphcate 
the  congenital  anomaly. 

Anomahes  in  the  kidney  and  ureter  which  may  be  demon- 
strated by  means  of  pyelo -ureterography  are  as  follows : 

1.  Duplication  of  the  renal  pelvis. 

2.  Duplication  of  the  ureter. 

3.  Fused  or  horseshoe  kidney. 

4.  Congenital  increase  or  decrease  in  the  size  of  the  pelvis. 

5.  Dystopic  kidney. 

DUPLICATION  OF  THE  RENAL  PELVIS 
Duplication  of  the  renal  pelvis  may  be  partial  or  com- 
plete, and  may  vary  in  degree  from  an  abnormal  elongation 
of  the  upper  calyx  to  two  distinct  and  widely  separated 

19  289 


290  PYELOGRAPHY 

pelves.  The  tendency  toward  duplication  of  the  pelvis 
is  frequently  seen  in  the  outline  of  an  otherwise  normal 
pelvis.  The  first  evidence  is  apparent  in  the  unusual 
elongation  of  the  upper  major  calyx.  The  calyx  may  appear 
unusually  large,  and  the  secondary  major  calyces  assume 
the  size  usually  seen  with  primary  calyces.  The  isthmus 
connecting  the  calyx  with  the  true  pelvis  and  the   upper 


Fig.  274. — Duplication  of  the  pelvis. 

calyx  may  be  narrow  and  rudimentary.  Such  duplica- 
tion is  necessarily  always  incomplete,  since  it  lacks  the 
separate  ureter.  In  Fig.  20  the  outline  of  the  renal  pelvis 
is  evidently  normal.  Our  attention,  however,  is  called  to 
the  upper  major  calyx,  which  is  larger  than  the  other 
calyces  and  has  a  dichotomous  branching.  It  is  connected 
with  the  lower  true  pelvis  by  an  elongated  narrow  isthmus 
which  practically  separates  it.     An  attempt  at  pelvic  re- 


CONGENITAL   ANOMALY 


291 


duplication  is  distinctly  present.  In  Fig.  274  a  short  isth- 
mus extends  from  the  upper  end  of  the  elongated  pelvis 
and  separates  it  from  what  may  be  regarded  either  as  a 
rudimentary  second  pelvis  or  a  major  calyx  with  secondary 
calyces.  In  Fig.  275  the  separation  of  the  upper  calyx  is 
seen  more  distinctly  and  is  apparently  a  distinct  pelvis 
divided  into  three  secondary  major  calyces  with  their  minor 


Fig.  275. — Duplication  of  the  pelvis. 

calyces.  The  isthmus  connecting  the  two  pelves,  or  rather 
the  two  portions  of  the  pelvis,  is  evidently  narrow  and  rudi- 
mentary. In  Fig.  276  the  outhne  of  two  pelves  with  their 
various  portions  which  go  to  make  a  complete  pelvis  is 
clearly  visible.  The  isthmus  connecting  the  two  true  pelves 
is  long  and  narrow.  Had  the  connecting  isthmus  entered 
the  ureter  separately  instead  of  the  lower  true  pelvis,  it 
would  have  been  regarded  as  a  branch  of  the  ureter  and  the 


292 


PYELOGRAPHY 


Fig.  276. — Duplication  of  the  pelvis. 


Fig.  277. — Duplication  of  the  pelvis. 


CONGENITAL   ANOMALY  293 

pelvic  duplication  would  have  been  complete.  In  Fig.  277 
the  major  and  minor  calyces  of  both  pelves  are  well  marked. 
The  isthmus  connecting  the  two  pelves  is  rudimentary  and 
might  be  regarded  as  an  extension  of  the  common  ureter. 
The  ureter  is  markedly  angulated  as  it  leaves  the  caudal 
surface  of  the  lower  pelvis.  In  Fig.  278  the  duplication  of 
the  pelvis  is  almost  complete.     Although  the  two  pelves  are 


Fig.  278. — Duplication  of  the  pelvis. 

separate,  they  are  in  such  close  relation  to  each  other  that 
they  might  still  be  called  portions  of  one  large  pelvis.  In- 
stead of  the  isthmus  connecting  the  two  pelves  directly,  as  in 
the  preceding  figures,  it  here  enters  directly  into  the  ureter 
at  the  site  of  the  ureteropelvic  juncture.  From  a  surgical 
point  of  view  the  duplication  would  hardly  be  complete. 
The  true  pelvis  of  the  upper  division  is  elongated  and 
narrowed  so  that  it  i^  practically  a  division  of  the  upper 


294 


PYELOGRAPHY 


branch  of  the  ureter.     The  three  branches  of  the  upper  pelvis 
or  major  calyces  are  quite  distinct. 

The  various  degrees  in  the  process  of  separation  were 
demonstrated  in  the  preceding  figures.  When  the  two  pelves 
have  separate  paths  of  drainage  into  the  ureter,  the  duplica- 
tion may  be  regarded  as  anatomically  complete.  However, 
unless  the  divisions  of  the  ureter  extend  well  beyond  the 


Fig.  279. — Duplication  of  the  pelvis. 


hilum,  the  duplication  is  hardly  complete  from  a  practical 
standpoint.  In  Fig.  279  the  two  divisions  of  the  pelvis  are 
quite  distinct,  but  they  unite  within  the  kidney  and  the  pel- 
vis could  hardly  be  considered  as  completely  duplicated. 
In  Fig.  280  the  separate  pelves  in  the  left  kidney  unite  just 
beyond  the  hilum.  A  distinct  demarcation  of  the  outline  of 
the  ureter  from  that  of  the  pelvis  is  apparent  a  short  distance 
above  the  place  of  ureteral  union.     In  Fig.  281  the  duplica- 


CONGENITAL   ANOMALY 


295 


Fig.  280. — Duplication  of  the  pelvis. 


Fig.  28L — Duplication  of  the  pelvis. 


296  PYELOGRAPHY 

tion  of  the  pelves  is  complete  and  the  separate  ureters  unite 
a  short  distance  beyond  the  hilum.  Of  particular  interest 
is  the  demarcation  of  the  outline  of  the  upper  division  of  the 
ureter  from  the  narrow  isthmus  connecting  the  upper  pelvis. 
In  Fig.  282  the  ureters  unite  a  short  distance  beyond  the 
ureteropelvic  juncture  of  the  lower  pelvis,  and,  although  the 
duplication  is  anatomically  complete,  bisection  of  the  kid- 


Fig.  282. — Duplication  of  the  pelvis. 

ney  would  be  difficult.     The  relation  of  the  upper  branch  of 
the  ureter  to  the  lower  pelvis  is  unusual. 

With  complete  pelvic  duplication  the  ureters  may  unite 
at  different  levels  below  the  ureteropelvic  juncture.  In 
Fig.  283  the  union  of  the  two  branches  of  the  right  ureter 
does  not  take  place  until  the  level  of  the  fourth  lumbar 
vertebra  is  reached.  Partial  reduplication  of  the  pelvis  is 
apparent  in  the  left  kidney.     In  Fig.  284  the  ureters,  in- 


CONGENITAL   ANOMALY 


297 


Fig.  283. — Duplication  of  the  pelvis. 


Fig.  284. — Duplication  of  the  pelvis. 


298  PYELOGRAPHY 

stead  of  combining  as  they  near  each  other,  merely  cross 
and  pursue  their  independent  courses. 

When  the  pelvis  is  duplicated  completely,  the  lower  pelvis 
is  usually  larger  and  more  completely  formed.  The  upper 
pelvis  is  usually  smaller,  has  fewer  calyces,  and  is  often 
rudimentary.  This  disparity  in  size  occurs  so  frequently 
that  if,  in  the  course  of  routine  pyelography,  the  outline  of 
the  pelvis  is  unusually  small  and  high  lying,  duplication  of 
the  pelvis  should  be  inferred  and  attempts  made  to  outline 
the  lower  pelvis.  In  Fig.  284  the  lower  pelvis  is  slightly 
larger  and  is  more  completely  formed  than  the  upper.  In 
Fig.  282  the  difference  in  size  between  the  upper  and  lower 
pelves  is  striking.  The  outlines  of  both  pelves  are  slightly 
dilated  as  the  result  of  chronic  infection.  In  Fig.  283  the 
size  of  the  two  pelves  is  approximately  equal.  In  Fig.  277, 
however,  the  upper  pelvis  is  larger  and  more  completely  de- 
veloped than  the  lower. 

A  possible  source  of  error  may  arise  should  the  patient 
breathe  while  the  pyelogram  is  being  made.  As  a  result, 
apparent  duplication  of  the  pelvis  and  upper  ureter  may  be 
present.  As  a  rule,  the  resulting  lateral  relation  of  the 
pelves  with  their  evident  overlapping  calyces  would  be  im- 
possible. With  extensive  respiratory  excursion,  however, 
the  outlines  of  the  pelves  may  be  well  separated.  In  Fig. 
285  the  apparent  duplication  of  the  pelvic  outline  and  upper 
ureter  was  the  result  of  respiration  while  the  pyelogram  was 
being  made.  The  relative  lateral  position  of  the  two  pelvic 
outlines  would  be  impossible  and  the  technical  error  is 
manifest. 

Not  infrequently  duplication  of  the  pelves  is  complete 
in  regard  to  separate  drainage  through  the  ureters,  but 
communication  between  the  two  pelves  will  remain  through 


CONGENITAL   ANOMALY  299 

adjacent  calyces.  That  is  to  say,  the  upper  major  calyx 
of  the  lower  pelvis  may  merge  with  the  lower  major  calyx 
of  the  upper  pelvis.  If  fluid  were  injected  into  one  pelvis, 
it  would  pass  through  the  communicating  calyces  into  the 
other  pelvis.  It  is  of  practical  importance  to  determine  the 
amount  of  tissue  which  separates  the  two  pelves.  If  a 
considerable  distance  separates  the  two  pelves,  the  ease  of 


Fig.  285. — Apparent  duplication  of  the  pelvis. 

surgical  bisection  is  rendered  greater.  When  the  two 
pelves  are  in  such  close  proximity  that  the  calyces  ap- 
parently overlap,  bisection  would  be  rendered  more  difficult. 
In  Fig.  286  the  upper  calyx  of  the  lower  pelvis  is  directly 
continuous  with  the  lower  calyx  of  the  upper  pelvis,  so  that 
the  connecting  isthmus  extends  between  calyces  instead  of  the 
true  pelvis,  as  in  preceding  cases.  Methylene-blue  solution 
injected  into  one  ureter  returned  through  the  other  ureter. 


300  PYELOGRAPHY 

With  duplication  of  the  pelvis  in  one  kidney,  a  tendency 
toward  duplication  or  unusual  increase  in  size  is  usually 
apparent  in  the  other.  Complete  duplication  of  the  pelves 
in  both  kidneys  with  separate  ureters  occurs  rarely.  In 
Fig.  283  the  duplication  of  the  pelves  in  the  right  kidney 
is  complete.  The  left  pelvis,  although  incompletely  dis- 
tended, shows  evidence  of  partial  duplication.     In  Fig.  286 


Fig.  286. — Bilateral  duplication  of  the  pelvis  and  ureter. 

the  pelvis  in  the  right  kidney  is  incompletely  duplicated, 
the  two  pelves  communicating  through  adjacent  calyces, 
as  previously  described.  In  Fig.  287  the  pelvis  in  the  left 
kidney  of  the  same  patient  is  completely  duplicated.  The 
outline  of  the  upper  pelvis  is  quite  normal,  while  that  of 
the  lower  pelvis  shows  evidence  of  considerable  inflamma- 
tory dilatation.  The  amount  of  tissue  separating  the  two 
pelves  would  easily  permit  of  bisection  of  the  kidney.     At 


CONGENITAL   ANOMALY  301 

operation  the  lower  half  of  the  kidney  was  found  largely 
destroyed  by  a  pyonephrotic  process  and  was  removed  from 
the  upper  portion.  The  remaining  half  of  the  kidney  was 
later  found  to  functionate. 


Fig.  287. — Duplication  of  the  pelvis  and  ureter  (same  as  Fig.  286). 

DUPLICATION  OF  THE  URETER 

DupHcation  of  the  ureter  as  in  the  pelvis  may  be  complete 
or  partial,  and  bilateral  or  unilateral.  With  complete  duplica- 
tion the  course  of  the  ureters  crosses  twice  before  entering  the 
bladder.  The  first  crossing  is  usually  visible  at  a  short  dis- 
tance below  the  ureteropelvic  juncture.  The  second  crossing 
is  visible  at  a  short  distance  above  the  bladder-wall.  As  a 
result,  the  ureter  leading  from  the  external  and  posterior 
meatus  will  be  found  to  lead  into  the  lower  of  the  two  renal 
pelves.     When  the  upper  crossing  is  visible,  it  may  be  inferred 


302 


PYELOGRAPHY 


that  the  duphcation  of  the  ureter  is  complete.  The  points  of 
crossing  are  at  the  site  where  union  of  the  two  branches  in 
incomplete  duplication  usually  occurs.  In  Fig.  288  the  left 
ureter  is  completely  duplicated.  The  separate  ureters  cross  at 
a  short  distance  below  the  ureteropelvic  juncture  of  the  lower 


Fig.  288. — Duplication  of  ureter  and  pelvis. 

pelvis.  They  cross  for  the  second  time  at  a  short  distance 
above  the  bladder-wall.  In  Fig.  284  only  the  upper  portion 
of  the  duplicated  ureters  is  visible.  The  two  ureters  cross 
at  a  short  distance  below  the  ureteropelvic  juncture. 

The  two  ureters  are  usually  separate  and  are  situated  at 


CONGENITAL   ANOMALY  303 

a  variable  distance  apart  througliout  their  course.  Occa- 
sionally, however,  the  two  ureters  lie  in  close  apposition, 
surrounded  by  a  common  fibrous  sheath  for  a  variable  dis- 
tance in  their  course.  In  rare  instances  such  closely  ap- 
proximated ureters  may  anastomose  in  a  portion  of  their 
course.  The  exact  relationship  between  the  two  ureters 
can  be  demonstrated  best  by  means  of  the  ureterogram. 

The  extent  of  the  duplication,  when  partial,  varies  con- 
siderably. It  may  involve  the  greater  portion  of  the  ureter 
or  be  confined  to  either  the  proximal  or  distal  segment. 
Partial  duplication  will  more  often  involve  the  proximal 
portion  of  the  ureter.  With  multiple  branching  of  the  first 
portion  of  the  ureter,  the  place  of  the  true  pelvis  may  be 
taken  by  two  or  more  branches  of  the  ureter  leading  directly 
into  independent  calyces.  The  several  branches  usually 
unite  at  the  usual  site  of  the  ureteropelvic  juncture,  and 
they  may  be  regarded  either  as  divisions  of  the  ureter  or 
as  elongated  renal  pelves.  Although,  with  division  of 
the  upper  ureter,  the  different  branches  more  often  unite 
at  or  near  the  usual  site  of  the  ureteropelvic  juncture,  they 
frequently  join  at  a  variable  distance  below  this  point. 
In  Figs.  280  and  281  the  divisions  of  the  ureter  may  either 
be  regarded  as  such  or  as  elongations  of  the  duplicated  pelves. 
In  Fig.  278  the  two  divisions  of  the  ureter  extend  from 
separate  pelves  as  far  as  the  ureteropelvic  juncture,  where 
they  unite.  In  Fig.  283  the  right  ureter  is  single  from  the 
bladder  meatus  up  to  the  level  of  the  fourth  lumbar  vertebra. 
From  this  point  the  ureter  is  duplicated  and  extends  into 
separate  pelves.  Had  the  opaque  catheter  alone  been  used, 
the  existence  of  this  duplication  would  have  been  overlooked. 
Further,   had  there  been  any  pathologic   complication  in 


304  PYELOGEAPHY 

either  of  the  pelves,  its  existence  could  have  been  ascer- 
tained clinically  only  by  means  of  the  pyelogram. 

With  duplication  involving  the  lower  portion  of  the 
ureter,  the  two  ureters  end  in  separate  meati  in  the  bladder. 
As  a  rule,  the  two  meati  are  situated  on  the  same  side  of 
the  trigone,  one  meatus  lying  posterior  and  lateral  to  the 


Fig.  289. — Duplication  of  the  ureter. 

other  and  separated  by  a  distance  of  from  1  to  3  cm.  Oc- 
casionally, however,  one  meatus  will  be  found  in  an  unusually 
median  position  while  the  other  meatus  may  be  situated 
posterior  and  lateral  at  a  distance  of  several  centimeters. 
When  the  duplication  of  the  ureter  is  partial  and  confined  to 
its  lower  segment,  the  two  meati  are  usually  situated  nearer 


CONGENITAL   ANOMALY 


305 


to  one  another  than  with  complete  duplication.  In  rare  in- 
stances, when  two  meati  are  situated  on  the  same  side  of  the 
trigone,  the  ureterogram  may  show  that  one  of  them  leads  into 
a  ureter  which  crosses  above  the  bladder  to  the  other  side. 

Duplication  confined  to  the  lower  end  of  the  ureter  is 
more  often  of  but  short  extent.  Frequently  but  one  cathe- 
ter can  be  inserted,  the  other  catheter  meeting  with  ob- 


i   ^^s-  C. 


Fig.  290. — Bilateral  duplication  of  the  ureter. 


struction  at  a  distance  of  a  centimeter  or  more  above  the 
meatus  or  at  the  point  of  anastomosis.  In  Fig.  289  the 
outlines  of  the  opaque  catheters  suffice  to  show  the  extent 
of  the  duplication,  which  extends  but  a  short  distance  above 
the  meatus  before  uniting.  The  picture  would,  however, 
have  been  more  complete  if  a  ureterogram  had  been  made. 
With  complete  duplication  of  the  ureter  on  both  sides  the 

20 


306  PYELOGRAPHY 

two  meati  are  usually  situated  on  either  side  of  the  trigone 
and  the  ureters  are  completely  duplicated.  Thus  in  Fig. 
290,  in  the  lower  portion,  the  two  ureters  are  seen  crossing 
on  either  side  at  a  short  distance  above  the  bladder-wall. 
They  are  again  seen  in  the  upper  plate,  Fig.  286,  extending 
to  the  pelves  and  crossing  a  short  distance  below. 

FUSED  KIDNEY 

Although  the  relative  position  of  the  two  divisions  of  a 
fused  kidney  can  often  be  determined  by  means  of  the 
shadow-casting  catheter,  nevertheless  more  accurate  localiz- 
ing data  can  usually  be  obtained  by  means  of  the  pyelo- 
gram.  Further,  the  pathologic  condition  which  so  fre- 
quently complicates  the  anomaly  can  better  be  determined 
by  its  means. 

The  two  pelves  of  a  fused  kidney  do  not,  as  a  rule,  lie 
symmetrically  with  respect  to  the  vertebral  column.  While 
the  exact  relationship  is  variable,  the  most  frequent  situation 
is  such  that  the  lower  lying  pelvis  is  visible  near  the  median 
line  and  the  upper  lying  pelvis  is  distinctly  lateral  and  more 
nearly  normal.  Occasionally  the  relative  position  of  the  two 
pelves  in  a  fused  kidney  may  become  confused  with  the  po- 
sition of  a  median-lying  dystopic  kidney  and  a  moderately 
low-lying  kidney.  As  a  rule,  however,  peculiarities  in  the 
position  and  character  of  the  low-lying  pelvis  as  well  as  in  its 
ureter  will  identify  the  condition  present.  As  with  unilateral 
duplication  of  the  pelvis,  the  upper  pelvis  of  the  fused  kidney 
is  usually  distinctly  smaller  than  the  lower  pelvis.  In  Fig. 
291  the  two  pelves  of  a  fused  kidney  are  visible.  The  upper 
pelvis  is  unusually  small,  and  is  separated  from  the  lower 
pelvis  by  enough  tissue  to  permit  of  bisection.  The  lower 
pelvis  is  distinctly  dilated,  the  hydronephrosis  being  caused 


CONGENITAL   ANOMALY 


3(J7 


by  constriction  in  the  ureter  a  short  distance  below  the  pel- 
vis. The  extent  of  the  hydronephrosis  is  obscured  by  the 
shadow  of  the  vertebrae. 

The  course  of  the  ureters  and  their  relation  to  their  re- 
spective pelves  in  the  fused  kidney  are  anomalous.  The 
ureter  is  frequently  markedly  tortuous  and  circuitous  in  its 


Fig.  291. — Fused  kidney — hydronephrosis  in  lower  pelvis. 


course  after  leaving  the  pelvis.  In  Fig.  292  the  two  pelves 
of  a  horseshoe  kidney  are  clearly  visible.  The  upper  pel- 
vis is  normal  in  size,  while  the  lower  pelvis  is  distinctly 
dilated  because  of  a  constriction  of  the  lower  ureter.  The 
ureter  appears  to  be  doubled  back  on  itself  before  entering 
the  posterior  surface  of  the  pelvis.     The  distance  separating 


308  PYELOGRAPHY 

the  pelves    shows  that  bisection  of  the  kidney  would  be 

possible. 

In  a  unilateral  pyelogram  the   possibility  of  a  fused  or 

horseshoe  kidney  should  be  considered  if  the  ureter  leaves 

the  pelvis  in  a  lateral  direction  instead  of  the  normal  median. 


Fig.  292. — Fused  kidney — hydronephrosis  in  lower  pelvis. 

In  Fig.  293  the  pelvis  and  ureter  of  the  left  segment  of  a 
horseshoe  kidney  are  outlined.  They  are  markedly  dilated 
as  the  result  of  mechanical  obstruction  in  the  lower  portion 
of  the  ureter  and  because  of  secondary  infection.     Of  par- 


CONGENITAL   ANOMALY  309 

ticular  interest  is  the  direction  in  which  the  ureter  leaves  the 
pelvis.  The  ureteropelvic  juncture  is  at  the  lateral  border 
of  the  pelvis,  instead  of  the  usual  median. 


Fig.  293. — Horseshoe  kidney — pyonephrosis  in  left  pelvis. 

CONGENITAL  LARGE  PELVIS 
With  a  congenital  solitary  or  asymmetric  kidney,  the 
increase  in  the  size  and  capacity  of  the  pelvis  is  usually 
commensurate  with  that  of  the  kidney.  In  Fig.  294,  al- 
though the  renal  pelvis  is  unusually  large,  the  outlines  of 
the  calyces  and  papillae  are  normal.  The  capacity  of  the 
pelvis  was  approximately  22  c.c,  as  ascertained  by  the  over- 
distention    method.     The    normal    terminal    irregularities, 


310 


PYELOGRAPHY 


the  outline  of  the  major  calyces,  and  the  shape  of  the  true 
pelvis  would  exclude  the  possibility  of  any  hydronephrosis 
being  present. 

Not  infrequently  one  kidney  is  found  to  be  unusually 
large  and  without  any  apparent  pathologic  reason  to  explain 
it.  In  such  cases  the  size  of  the  pelvis  is  usually  not  com- 
mensurate with  that  of  the  kidney.  Where  a  kidney  becomes 
increased  in  size  because  of  destruction  of  the  other  kidney, 


Fig.  294. — Solitary  kidney. 

the  size  of  the  pelvis  is  not,  as  a  rule,  increased  to  a  relative 
extent. 

Occasionally  in  the  course  of  routine  pyelography  we  are 
astonished  to  find  the  existence  of  unusually  large  pelves 
in  patients  who  have  little  or  no  objective  symptoms  sug- 
gestive of  renal  lesion,  and  in  whom  we  have  no  other  cysto- 
scopic  data  indicative  of  mechanical  obstruction  in  the 
ureter.  The  enlargement  is  usually  bilateral,  and  is  charac- 
terized by  marked  elongation  of  the  true  pelvis.   The  calyces 


CONGENITAL   ANOMALY  311 

are  well  formed,  but  are  exceptionally  broad  at  the  base. 
The  apices  and  minor  calyces  appear  normal  in  contra- 
distinction to  the  marked  changes  which  usually  occur  with 
pelvic  enlargement  with  hydronephrosis.  The  condition 
should  not  be  confused  with  a  dilatation  of  the  pelvis  and 
ureter  which  is  of  congenital  etiology  and  has  been  called 
congenital  atony  of  the  renal  pelvis.     This  latter  conditirjii 


Fig.  295. — Congenital  large  pelvis. 

is  differentiated  by  an  accompanying  dilatation  of  the 
ureter  throughout  its  extent,  which  does  not  occur  with  the 
congenital  large  pelvis.  Further,  with  congenital  atony, 
the  outline  of  the  renal  pelvis  is  typical  of  a  hydronephrosis. 
In  Fig.  295  the  pelves  on  both  sides  are  found  to  be  unusually 
large.  The  calyces,  although  broad,  show  the  normal  ter- 
minal irregularities  and  normal  indentation  of  papillae. 
The  true  pelvis  itself  is  elongated  and  shows  a  marked 


312 


PYELOGRAPHY 


tendency  toward  duplication,  particularly  on  the  right  side. 
But  one  ureter  is  present,  and  it  leaves  the  lower  division  of 
the  pelvis.  In  all  probabihty  this  condition  is  an  attempt 
at  duplication  of  the  renal  pelvis,  with  relative  increase  in 
the  size  of  the  kidney.  In  Fig.  296  the  outline  of  the  large 
pelvis  is  suggestive  of  a  pyonephrosis.     The  terminal  ir- 


Fig.  296. — Congenital  large  pelvis. 

regularities  and  indentations  of  the  minor  calyces  are  normal 
and  well  preserved.  The  urine  from  the  kidney  was  normal 
in  character.  The  ureter  shows  no  evidence  of  inflamma- 
tory dilatation. 

Congenital  decrease  in  the  size  of  the  pelvis  occurs  with 
congenital  atrophy  of  the  kidney.  This  condition,  while 
rare,  is  occasionally  seen,  and  is  to  be  remembered  when 


CONGENITAL   ANOMALY  313 

evidence  of  hypertrophy  is  apparent  in  the  opposite  kidney. 
As  a  rule,  the  diminished  secretion  and  evidence  of  atrophy 
in  the  meatus  and  ureter  call  one's  attention  to  the  dimin- 
ished function.  In  the  pyelogram  the  pelvic  outline  appears 
small.  The  calyces,  while  rudimentary,  show  no  evidence 
of  inflammatory  change. 

Dystopic  kidney  has  been  considered  in  Chapter  IV. 


BIBLIOGRAPHIC   INDEX 


Albarran,  21,  24 

Baker,  19 

Blum,  27 

Braasch,  20,  21,  22,  23, 

Bruce,  19,  23 

Buerger,  27 

Burkhardt,  18 

Carot,  23 
Childs,  21 
Clark,  21,  24 

DiETLEN,  19,  24,  26 
Doderlein,  IS 
Dohan,  26 

Eisendrath,  31 

Ekehorn,  27 
Ertzbischoff,  21,  24 

Fenwick,  17 
Fowler,  20,  22,  23 
Furniss,  23,  25,  27 

HOFMAN,  29 

Holland,  26 

Illyes,  17 

Jaches,  23,  25 
Jervell,  27 
Joseph,  25 

Keene,  23,  24,  25,  26 
Kelly,  19,  28 
Key,  22,  24 
Keyes,  18,  22 
Kidd,  20,  25,  30 
Klose,  17 


24,  25,  26,  27 


Kolischer,  17 
Kronig,  18 

Legueu,  23,  28 

Lewis,  19,  28 

Lichtenberg,  18,  19,  21,    22,    24,    25, 

26,  37 
Lowenhardt,  17 

Maingot,  23 
Mason,  28 
Morgandies,  29 

Necker,  23,  24 

Nemenow,  25 

Nogier,  21,  23,  24,  25,  26 

Oehlecker,  19,  20,  23,  24,  25,  26,  27 

Papin,  23,  28 
Paschkis,  24 
Pfahler,  18,  19 
Polano,  IS 

Rehn,  31 

Reynard,  21,  23,  24,  25,  26 

Roessle,  29 

Rosenblatt,  29 

Schmidt,  17 
Schramm,  20 
Schwarzwald,  28 
Seelig,  25 
Smith,  29 
Spitzer,  21 
Stanton,  19 
Strassman,  30 


Tennant,  28,  30 
Thomas,  19 


315 


316 


BIBLIOGRAPHIC    INDEX 


Trendelenburg,  20,  21,  24,  40,  86,  143, 

166,  168 
Troell,  28 
Tuffier,  17 

Uhle,  18,  19,  26 

Vest,  28,  29 

Voelcker,  18,  21,  22,  23,  24,  25,  28,  37 


von  Illyes,  17 

von  Lichtenberg,   18,   19,  21,  22,  24, 
25,  26,  37 

Walker,  23,  28 

Wolff,  287 
Wossidlo,  30 

Zachrisson,  27 


NDEX  OF  SUBJECTS 


Abnormal  position  of  kidney,  79 
of  pelvis  in  renal  tumor,  265 
Absence  of  shadow  in  radiography  of 

renal  stone,  192 
Accidents    in    pyelography,    history, 

27 
Alternating   contraction   and   dilata- 
tion, 164 
Anastomoses,  apparent,  of  calyces,  63 
Anomaly,  congenital,  of  kidney,  289 

of  ureter,  289 
Appearance  of  major  calyces,  44,  55 

of  minor  calyces,  44 

of  normal  pelvis,  44 

of  true  pelvis,  44 
Areas   of    cortical   necrosis    in   renal 

tuberculosis,  174 
Argyrol  in  pyelography,  18 
Atrophic  contraction  of  pelvis,   165 
Axis  of  pelvis,  54 

Bibliography,  32-35 

Bismuth  emulsion  in  pyelography,  18 

Calyces,  apparent  anastomoses  of,  63 

dilatation  predominant  in,  147 

major,  appearance  of,  44,  55 

minor,  appearance  of,  44 

outline  of,  65 

retraction  of,  in  renal  tumor,  252 
Calyx,  renal  stone  in,  202 
Capacity,  functional,  of  kidney,  esti- 
mate, 135 

of  true  pelvis,  48 
Carcinoma,  dilatation  of  true  pelvis 

in,  265 
Cargentos  in  pyelography,  18 
Cases,  selection  of,  36 
Catheter,  moderately  opaque,  for  pye- 
lography, 40 


Catheter,  unusual  length  of,  in  diag- 
nosis of  hydronephrosis,  125 
ureteral,  in  diagnosis  of  large  hy- 
dronephrosis, 120 
Causes  of  ureteral  obstruction,   136 
Cicatricial  constriction  of  ureter,  142 
Colic,  renal,  in  renal  tuberculosis,  136 
CoUargol  in  pyelography,  18 

solution  for  injection,  37 
Colloidal  silver  in  pyelography,  18 
persistence  of,  in  hydronephrosis, 

130 
solution  for  injection,  37 
Comparison  of  pyelograms,  value  of, 

90 
Congenital  anomaly  of  kidney,  289 
diagnosis,  25 
of  ureter,  289 
large  pelvis,  309 
Constriction,  cicatricial,  of  ureter,  142 
Contour  of  pelvis,  54 
Contraction  and  dilatation,  alternat- 
ing, 164 
of  pelvis,  atrophic,  165 
Contraindications  to  pyelography  of 

renal  tumor,  273 
Cortical  stone,  207 
Course  of  normal  ureter,  74 
Cyst,  renal,  solitary,  285 
Cystoscope  in  diagnosis  of  large  hy- 
dronephrosis, 120 

Death  after  pyelography,  29 
Deformity  at  ureteropelvic  juncture 
in  renal  tumor,  268 
of  upper  ureter  in  renal  tumor,  268 
pelvic,  from  renal  neoplasm,  252 

in  sarcoma,  252 
spider-leg,  in  renal  tumor,  255 
Destruction  of  pelvic  outline,  160 


317 


318 


INDEX   OF    SUBJECTS 


Diagnosis,   differential,   of  gall-stone 
and  renal  stone,  217 
of  normal  pelvis  and  early  hydro- 
nephrosis, 104 
of  pyelitis  and  renal  tuberculosis, 

174 
of  renal  stone,  190 
tumor,  274 
of  congenital   anomaly   of  kidney, 

25 
of  early  hydronephrosis,  course  of 

ureter  in,  110 
of  hydronephrosis,   21,   22,   99 
etiologic  factors,  125 
unusual  length  of  catheter  in,  125 
value  of  pyelography  in,  124 
of      hydro-ureter,      pyelo-uretero- 

gram  in,  136 
of  inflammatory  changes,  23 
of  large  hydronephrosis  by  cysto- 
scope,  120 
by  ureteral  catheter,  120 
of  polycystic  kidney,  25 
of  renal  stone,  26 
tuberculosis,  24,  172 
tumor,  24 
of  small  hydronephroses,  bilateral 

pyelogram  in,  106 
of  stricture  of  ureter,  27,  143 
of  ureteral  obstruction,  26 
stricture,  27 
Diagnostic  data,  history  of,  21 

significance    of    immediate    return 

flow,  247 
value  of  pyelography,  21 
Differential    diagnosis    of    gall-stone 
and  renal  stone,  217 
of  renal  stone,  190 
tumor,  274 
Dilatation  above  ureteral  shadow  in 
ureteral  stone,  233 
and  contraction,  alternating,   164 
inflammatory,  145 
involving  entire  pelvis,   154 
mechanical,  98 

of  pelvis  in  renal  stone,  189 
nodular,  of  ureter  in  ureteral  stone, 
227 


Dilatation    of   both   ureters,   causes, 
143 
of  pelvis  in  renal  stone,  186 

tuberculosis,  174 
of  renal  pelvis,  145 
of  true  pelvis  in  carcinoma,  265 

in  renal  tumor,  264 
of  ureter  below  ureteral  stone,  246 

from  secondary  infection,  246 
predominant  in  calyces,  147 
in  pelvis,  152 
in  ureter,  155 
Displacement  of  pelvic  outline  from 

extrarenal  tumor,  278 
Dorsal  position  for  pyelography,  40 
Duplication  of  lower  end  of  ureter, 
305 
of  renal  pelvis,  289 
of  ureter,  301 
Dystopic  kidney,  95 

Elasticity  of  ureter,  78 
Electrargol  in  pyelography,  18 
Enlargement  of  true  pelvis  in  hydro- 
nephrosis, 103 
Error  in  technic,  sources  of,  41 
Estimate   of  functional    capacity   of 

kidney,  135 
Estimation  of  renal  function,  214 
Etiologic  factors  in  diagnosis  of  hy- 
dronephrosis, 125 
Experiments,  injection,  on  dogs,  31 
on  rabbits,  30 
on  sheep,  30 
Extrarenal  tumor,  277 

displacement    of    pelvic    outline 
from,  278 
Extra-ureteral  shadow,  248 

Function,  renal,  estimation  of,  214 
Fused  kidney,  306 

Gall-stone,  216 

and  renal  stone,  differential  diag- 
nosis, 217 
Gas  injection  method,  18 

pyelogram,  43 
Gravity  injection  apparatus,  19 


INDEX   OF    SUBJECTS 


319 


(Jravity  method  of  injection,  38 
advantages,  38 
injury  prevented  by,  42 

Hand   sj^ringe   method   of   injection, 

38 
Hematuria,    renal,    pyelography    in. 

275 
History  of  accidents  in  pyelography, 
27 
of  diagnostic  data,  21 
of  pyelography,  17-32 
Hydronephroses,  large,  119 

small,  bilateral  pyelogram  in  diag- 
nosis, 106 
Hydronephrosis,  98 

deviations  of  pelvic  outline  from, 

98 
diagnosis,  22,  99 

unusual    length   of    catheter    in, 
125 
early,  99 

and    normal    pelvis,    differential 

diagnosis,  104 
appearance  of,  100 
etiologic  factors  in  diagnosis,   125 
from  movable  kidney,  126 
from  scoliosis,  130 
in  renal  stone,  190 
intrarenal,  134 
large,  diagnosis  by  cystoscope,  120 

by  ureteral  catheter,  120 
moderate,  112 

appearance  of  true  pelvis  in,  112 
of  pregnancy,  origin  of,  126 
persistence  of  colloidaJ  silver  in,  130 
post-operative  course  of,  132 
secondary  infection  in,  127 
value  of  pyelography  in  diagnosis, 
124 
Hydro-ureter,  135 

pyelo-ureterogram  in  diagnosis  of, 
136 

Identification  of  renal  shadows,  26, 
183 
pyelographic  data  for,  184 
of  ureteral  shadows,  26 


Infection,      secondarj',      in      hydro- 
nephrosis, 127 
in  polycystic  kidney,  282 
ureteral  dilatation  from,  246 
Inflammation  of  ureter,  166 
Inflammatory  changes,  diagnosis,  23 
in  renal  stone,  187 
dilatation,  145 

stenosis,  secondary,  immediate  re- 
turn flow  from,  247 
Injection  by  gravity  method,  38 
advantages,  39 
by  hand-syringe  method,  38 
coUargol  solution  for,  37 
colloidal  silver  solution  for,  37 
experiments  on  dogs,  31 
on  rabbits,  30 
on  sheep,  30 
medium,  selection  of,  37 
method  of  making,  38 
of  .solution,  pain  in,  21,  39 
silver  iodid  emulsion  for,  37 
solution,  preparation,  37 
Injurious  results  of  pyelography,  41 
Injury  prevented  by  gravity  method 

of  injection,  42 
Intrarenal  hydronephrosis,  134 
Involvement     of     ureter     in     renal 
tumor,  287 

Kidney,  abnormal  position  of,  79 
congenital  anomaly  of,  289 

diagnosis,  25 
dystopic,  95 
estimate  of  functional  capacity  of, 

135 
fused,  306 
movable,  79 

hydronephrosis  from,  126 

surgical  interference  in,  80 
pelvic,  95 
polycystic,  278 

diagnosis,  25 

secondary  infection  in,  282 

Localization  of  renal  shadows,  26 
of  shadow  of  renal  stone,  192 


320 


INDEX   OF   SUBJECTS 


Location  of  stone  shadows,  solution 
for,  193 

Mechanical  dilatation,  98 

of  pelvis  in  renal  stone,  189 

Method  of  injection,  38 

Movable  kidney,  79 

hydronephrosis  from,  126 

Nargol  in  pyelography,  18 
Necrosis,  cortical,  areas  of,  in  renal 

tuberculosis,  174 
Neoplasm,    renal,    pelvic    deformity 

from,  252 
Normal  ureter,  73 

Outline  of  minor  calyx,  65 
of  true  pelvis,  46 

Pain  on  injection  of  solution,  21,  39 
Pathologic   findings   in   renal   tuber- 
culosis, 136 
Patient,  position  of,  20 
Pelvic    deformity    from    renal    neo- 
plasm, 252 
in  sarcoma,  252 
dilatation  predominant  in  calyces, 

147 
kidney,  95 
lumen,     encroachment     of     renal 

tumor  on,  259 
outline,  destruction  of,   160 

deviations  of,  from  hydronephro- 
sis, 98 
displacement     of,     from     extra- 
renal tumor,  278 
Pelvis,     abnormal     position     of,     in 
renal  tumor,  265 
and  ureter,  relation  of,  70 
atrophic  contraction  of,  165 
axis  of,  54 

congenital  fused,  309 
contour  of,  54 

dilatation  of,  in  renal  stone,  186 
in  renal  tuberculosis,  174 
predominant  in,  152 
entire,  dilatation  involving,  154 


Pelvis,  mechanical  dilatation   of,  in 
renal  stone,  189 
normal,  and  early  hydronephrosis, 
differential  diagnosis,  104 
appearance  of,  44 
outline  of,  relation  of  shadows  to, 

185      • 
renal,  dilatation  of,  145 
duplication  of,  289 
tumor  of,  276 
true,  appearance,  44 

in    moderate    hydronephrosis, 
112 
capacity  of,  48 
dilatation  of,  in  renal  tumor,  264, 

265 
enlarged,  in  hydronephrosis,  103 
outline  of,  46 
renal  stone  in,  193 
Persistence  of  colloidal  silver  in  hy- 
dronephrosis, 130 
Plate,  size  of,  for  pyelography,  20 
Plug-hat  pelvis,  22 
Polycystic  kidney,  278 
diagnosis,  25 

secondary  infection  in,  282 
Position,  abnormal,  of  kidney,  79 
of  normal  renal  pelvis,  69 
of  patient,  20 
Post-operative  course  of  hydroneph- 
rosis, 132 
Pregnancy,  origin  of  hydronephrosis 

and  consequent  pj^elitis  in,  126 
Preparation  of  injection  solution,  37 
of  solution  used  in  pyelography,  20 
Pyelitis,  145 

and  renal  tuberculosis,  differential 

diagnosis,  174 
of  pregnancy,  origin  of,  126 
Pyelogram,  gas,  43 
Pyelograms,  value  of  comparison  of, 

90 
Pyelographic  data  for  identification 
of  shadows,  184 
findings  in  renal  stone,  187 
Pyelography,  death  after,  29 
diagnostic  value  of,  21 
first  attempt  at,  17 


INDEX    OF    SUBJECTS 


321 


Pyelography,  history  of,  17-32 
of  accidents  in,  27 
of  technic,  17 
in  renal  hematuria,  275 
in  renal  tumor,  contra-iiulications 
to,  273 
sources  of  error  in,  271 
size  of  plate  for,  20 
strength  of  solution  for,  21 
technic  of,  36 

value   of,    in   diagnosis   of   hj'dro- 
nephrosis,  124 
Pyelo-ureterogram     in    diagnosis    of 

hydro-ureter,  136 
Pyelo-ureterography,  17 
Pyonephrosis,  160 

Radiography  of  renal  stone,  absence 

of  shadow  in,  192 
Reaction  from  injection  of  colloidal 

silver,  27 
Relation  of  pelvis  and  ureter,  70 
Renal  colic  in  renal  tuberculosis,  130 
cyst,  solitary,  285 
function,  estimation  of,  214 
hematuria,  pyelography  in,  275 
neoplasm,   pelvic   deformity   from, 

252 
pelvis,  dilatation  of,  145 
duplication  of,  289 
normal,  position  of,  69 
tumor  of,  276 
shadows,  identification,  26 

localization,  26 
stone,  183 
diagnosis,  26 

differential,  190 
dilatation  of  pelvis  in,  186 
hydronephrosis  in,  190 
in  calyx,  202 
in  cortex,  207 
in  true  pelvis,  193 
inflammatory  change  in,  187 
localization  of  shadow  of,  192 
mechanical   dilatation   of   pelvis 

in,  189 
multiple,  shadows  of,  210 
pyelographic  findings  in,  187 
21 


R{(nal  stone,  radiography  of,  absence 
of  shadow  in,  192 
torsion.  94 
tuberculosis,  172 

and    pyelitis,    differential    diag- 
nosis, 174 
areas  of  cortical  necrosis  in,  174 
diagnosis,  24,  172 
dilatation  of  pelvis  in,  174 
pathologic  findings,  136 
renal  colic  in,  136 
stricture  of  ureter  in,  174 
tumor,  252 

abnormal   position  of   pelvis  in, 

265 
contraindications  to  pyelography 

of,  273 
deformity  at  ureteropelvic  junc- 
ture in,  268 
of  upper  ureter  in,  268 
diagnosis,  24 

differential.  274 
dilatation   of  true  pelvis  in,  264 
encroachment  on  pelvic  lumen, 

259 
involvement  of  ureter  in,  287 
retraction  of  calyces  in,  252 
sources  of  error  in  pyelography 

of,  271 
spider-leg  deformity  in,  255 
Retraction  of  calyces  in  renal  tumor, 

252 
Return   flow,    immediate,    diagnostic 
significance,  247 
from  secondary  inflammatory 

stenosis,  247 
from  ureteral  stone,  247 

Sarcoma,  pelvic  deformity  in,  252 
vScoliosis,  hydronephrosis  from,  130 
Secondary  infection  in  hydronephro- 
sis, 127 
in  polycystic  kidney,  282 
Selection  of  cases,  36 

of  injection  medium,  37 
Shadow,  absence  of,  in  radiography 
of  renal  stone,  192 
extra-ureteral,  248 


322 


INDEX    OF    SUBJECTS 


Shadow,  identification,  183 
of  multiple  renal  stone,  210 
of-  renal  stone,  localization  of,  192 
stone,  solution  for  location  of, 
198 
relation  of,  to  outline  of  pelvis,  185 
Silver  iodid  emulsion  for  pyelography, 
19,  37 
oxid  for  pyelography,  18 
solutions,  colloidal,  in  pyelography, 
IS 
Size  of  plate  for  pyelography,  20 
Solitary  renal  cyst,  285 
Solution  for  injection,  preparation  of, 
20 
for  location  of  stone  shadows,  193 
for  pyelography,  strength  of,  21 
Sources   of   error  in  pyelography   of 

renal  tumor,  271 
Spider-leg  deformity  in  renal  tumor, 

255 
Stenosis,     secondary     inflammatory , 

immediate  return  flow  from,  247 
Stone,  renal,  183 

and  gall-stone,  differential  diag- 
nosis, 217 
differential  diagnosis,  190 
dilatation  of  pelvis  in,  186 
hydronephrosis  in,  190 
in  calyx,  202 
in  cortex,  207 

inflammatory  change  in,  187 
in  true  pelvis,  193 
localization  of  shadow  of,  192 
mechanical   dilatation   of   pelvis 

in,  189 
multiple,  shadows  of,  210 
pyelographic  findings  in,  187 
radiography  of,  absence  of  shad- 
ow in,  192 
shadows,  solution  for  location  of, 

193 
ureteral,  227 

dilatation  above  ureteral  shadow 
in,  233 
of  ureter  below,  246 
immediate  return  flow  from,  247 
nodular  dilatation  of  ureter  in,  227 


Stricture  of  ureter,  diagnosis,  27,  143 

in  renal  tuberculosis,  174 
Surgical  interference  in  movable  kid- 
ney, 80 

Technic  of  pyelography,  36 

history,  17 
Technical  error,  sources  of,  41 
Torsion,  renal,  94 

Trendelenburg  position  for  pyelogra- 
phy, 40 
Tuberculosis,  renal,  172 

and    pyelitis,    differential    diag- 
nosis, 174 
areas  of  cortical  necrosis  in,  174 
diagnosis,  172 
dilatation  of  pelvis  in,  174 
pathologic  findings,  136 
renal  colic  in,  136 
stricture  of  ureter  in,  174 
Tumor,  extrarenal,  277 

displacement    of    pelvic    outline 
from,  278 
of  renal  pelvis,  276 
pressure    from,    cause    of   ureteral 

dilatation,  139 
renal,  252 

abnormal  position  of  pelvis  in, 

265 
contraindications    to    pyelogra- 
phy of,  273 
deformity  at  ureteropelvic  junc- 
ture in,  268 
of  upper  ureter  in,  268 
differential  diagnosis  of,  274 
dilatation  of  true  pelvis  in,  264 
encroachment  on  pelvic  lumen, 

259 
involvement  of  renal  tumor  in, 

287 
retraction  of  calyces  in,  252 
sources  of  error  in  pyelography 

of,  271 
spider-leg  deformity  in,  255 

Ureter  and  pelvis,  relation  of,  70 
cicatricial  constriction  of,  142 
congenital  anomaly  of,  289 


INDEX    OP^    SUBJECTS 


323 


Ureter,  course  of,  in  diagnosis  of  early 

hydronephrosis,  110 
dilatation  of,  below  ureteral  stone, 
246 

from  secondary  infection,  246 

predominant  in,  155 
duplication  of,  301 
elasticity  of,  78 
inflammation  of,  166 
involvement    of,    in    renal     tumor, 

287 
lower  end,  duplication  of,  305 
nodular  dilatation  of,   in  ureteral 

stone,  227 
normal,  73 

course  of,  74 
stricture  of,  diagnosis,  143 

in  renal  tuberculosis,  174 
upper,  deformity  of,  in  renal  tumor, 

268 
Ureteral  dilatation  caused  by  pressure 
from  tumor,  139 


Ureteral  dilatation,  conditions  caus- 
ing, 140 
obstruction,  124 
causes  of,  136 
diagnosis,  26 
shadows,  dilatation  above,  in  ure- 
teral stone,  233 
identification  of,  26 
stone,  227 

dilatation  above  ureteral  shadow 
in,  233 
of  ureter  below,  246 
immediate  return  flow  from,  247 
nodular  dilatation   of   ureter   in, 
227 
Ureteritis,  166 
Urcteropelvic  juncture,  deformity  at, 

in  renal  tumor,  268 
Ureters,  both,  causes  of  dilatation  of, 
143 

Xeroform  in  pyelography,  18 


JAN  3     1950 


